Healthcare Provider Details

I. General information

NPI: 1487936647
Provider Name (Legal Business Name): PEGAH GHASSEMI BAKHTIARI DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2011
Last Update Date: 03/17/2022
Certification Date: 03/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12756 W WASHINGTON BLVD
LOS ANGELES CA
90066-2309
US

IV. Provider business mailing address

12756 W WASHINGTON BLVD
LOS ANGELES CA
90066-2309
US

V. Phone/Fax

Practice location:
  • Phone: 310-822-6066
  • Fax:
Mailing address:
  • Phone: 310-822-6066
  • Fax: 310-578-8200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number64404
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: