Healthcare Provider Details

I. General information

NPI: 1861591521
Provider Name (Legal Business Name): HIRI ETESSAMI DDS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 03/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9201 SUNSET BLVD SUITE 908
LOS ANGELES CA
90069
US

IV. Provider business mailing address

9201 SUNSET BLVD SUITE 908
LOS ANGELES CA
90069
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 TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number37329
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDC35209
License Number StateCA

VIII. Authorized Official

Name: DR. HIRBOD ETESSAMI
Title or Position: OWNER PARTNER
Credential: DDS
Phone: 310-550-0506