Healthcare Provider Details

I. General information

NPI: 1619644804
Provider Name (Legal Business Name): ARDALAN ESAKHARIAN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2021
Last Update Date: 01/20/2022
Certification Date: 01/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

813 FAIR OAKS AVE
S PASADENA CA
91030-2605
US

IV. Provider business mailing address

1420 REXFORD DR APT 5
LOS ANGELES CA
90035-3154
US

V. Phone/Fax

Practice location:
  • Phone: 626-593-0053
  • Fax:
Mailing address:
  • Phone: 310-403-5945
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDDS107239
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: