Healthcare Provider Details

I. General information

NPI: 1124372784
Provider Name (Legal Business Name): COHEN SEDGH, MANAVI & PAKRAVAN DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2012
Last Update Date: 06/27/2022
Certification Date: 06/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

154 W FOOTHILL BLVD SUITE C-2A
MONROVIA CA
91016-2171
US

IV. Provider business mailing address

154 W FOOTHILL BLVD SUITE C-2A
MONROVIA CA
91016-2171
US

V. Phone/Fax

Practice location:
  • Phone: 310-820-9933
  • Fax: 310-820-0408
Mailing address:
  • Phone: 310-820-9933
  • Fax: 310-820-0408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number38979
License Number StateCA

VIII. Authorized Official

Name: SOLEYMAN COHEN SEDGH
Title or Position: OWNER
Credential:
Phone: 310-820-9933