Healthcare Provider Details

I. General information

NPI: 1144152331
Provider Name (Legal Business Name): LASTING SMILES OF WEST COVINA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1710 W CAMERON AVE STE 100
WEST COVINA CA
91790-2720
US

IV. Provider business mailing address

PO BOX 18538
ANAHEIM CA
92817-8538
US

V. Phone/Fax

Practice location:
  • Phone: 626-962-4428
  • Fax: 626-962-9789
Mailing address:
  • Phone: 626-962-4428
  • Fax: 626-962-9789

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: SHARAM GHODSI
Title or Position: PRESIDENT
Credential: DDS
Phone: 714-206-3762