Healthcare Provider Details

I. General information

NPI: 1154410256
Provider Name (Legal Business Name): KEIVAN SARRAF DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 03/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5703 S VERMONT AVE
LOS ANGELES CA
90037-3930
US

IV. Provider business mailing address

5703 S VERMONT AVE
LOS ANGELES CA
90037-3930
US

V. Phone/Fax

Practice location:
  • Phone: 323-751-5600
  • Fax:
Mailing address:
  • Phone: 323-751-5600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number52466
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: