Healthcare Provider Details

I. General information

NPI: 1790398964
Provider Name (Legal Business Name): BEHRAD VAHDATI NIA DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2020
Last Update Date: 08/27/2020
Certification Date: 08/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

514 E WASHINGTON BLVD
LOS ANGELES CA
90015-3723
US

IV. Provider business mailing address

P.O. BOX #249 10586 W PICO BLVD
LOS ANGELES CA
90064
US

V. Phone/Fax

Practice location:
  • Phone: 213-749-3934
  • Fax:
Mailing address:
  • Phone: 408-857-5701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDDS105234
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: