MEDICARE: SIMON HEDVAT DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	110189	CA
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1255021804
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SIMON HEDVAT DMD

Provider Business Mailing Address
First Line	:	339 N OAKHURST DR APT 203
Second Line	:
City	:	BEVERLY HILLS
State	:	CA
Zip	:	90210-4162
Country	:	US
Telephone Number	:	310-990-9790
Fax Number	:

Provider Business Practice Location Address
First Line	:	1260 15TH ST STE 703
Second Line	:
City	:	SANTA MONICA
State	:	CA
Zip	:	90404-1142
Country	:	US
Telephone Number	:	310-393-8284
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/08/2023
Last Update Date	:	10/23/2025

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