Healthcare Provider Details

I. General information

NPI: 1285952234
Provider Name (Legal Business Name): SAMAN VAHEDI D.D.S., M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2010
Last Update Date: 09/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1171 S ROBERTSON BLVD # 225
LOS ANGELES CA
90035-1403
US

IV. Provider business mailing address

12300 WILSHIRE BLVD, SUITE 326
LOS ANGELES CA
90025
US

V. Phone/Fax

Practice location:
  • Phone: 310-927-7666
  • Fax:
Mailing address:
  • Phone: 310-954-9449
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number63560
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberA151497
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: