Healthcare Provider Details

I. General information

NPI: 1629407135
Provider Name (Legal Business Name): HIRI ETESSAMI DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/05/2013
Last Update Date: 04/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9201 W SUNSET BLVD STE 908
LOS ANGELES CA
90069-3710
US

IV. Provider business mailing address

9201 W SUNSET BLVD STE 908
LOS ANGELES CA
90069-3710
US

V. Phone/Fax

Practice location:
  • Phone: 310-550-0506
  • Fax: 310-550-0613
Mailing address:
  • Phone: 310-550-0506
  • Fax: 310-550-0613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number37329
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: