Healthcare Provider Details

I. General information

NPI: 1073702833
Provider Name (Legal Business Name): SOHRAB IMANI D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2990 S SEPULVEDA BLVD STE 304
LOS ANGELES CA
90064-3996
US

IV. Provider business mailing address

PO BOX 641935
LOS ANGELES CA
90064-6935
US

V. Phone/Fax

Practice location:
  • Phone: 310-400-0337
  • Fax:
Mailing address:
  • Phone: 310-400-0337
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number53073
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: