Healthcare Provider Details

I. General information

NPI: 1689919995
Provider Name (Legal Business Name): COHEN SEDGH, MANAVI & PAKRAVAN DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2012
Last Update Date: 11/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1423 E GAGE AVE SUITE A
LOS ANGELES CA
90001-1771
US

IV. Provider business mailing address

1423 E GAGE AVE SUITE A
LOS ANGELES CA
90001-1771
US

V. Phone/Fax

Practice location:
  • Phone: 323-983-4000
  • Fax: 323-983-4007
Mailing address:
  • Phone: 323-983-4000
  • Fax: 323-983-4007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number39862
License Number StateCA

VIII. Authorized Official

Name: DR. FARID PAKRAVAN
Title or Position: OWNER
Credential:
Phone: 310-820-9933