Healthcare Provider Details

I. General information

NPI: 1013834613
Provider Name (Legal Business Name): JASON JACOB SHADPOUR DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2026
Last Update Date: 07/02/2026
Certification Date: 07/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 W 34TH ST
LOS ANGELES CA
90089-0058
US

IV. Provider business mailing address

9774 SAN CIR
BEVERLY HILLS CA
90210-1516
US

V. Phone/Fax

Practice location:
  • Phone: 213-740-2805
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number113314
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: