MEDICARE: SHAHROKH JEDIAN DDS

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	1223G0001X	General Practice Dentistry

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1407052814	OTHER	CA	NPI

General Provider Information

NPI Number	:	1275779795
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHAHROKH JEDIAN DDS

Provider Business Mailing Address
First Line	:	998 S ROBERTSON BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90035-1637
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	998 S ROBERTSON BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90035-1637
Country	:	US
Telephone Number	:	310-358-1200
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	SHAHROKH JEDIAN
Credential	:
Telephone Number	:	310-404-6476

Provider Enumeration Date	:	01/05/2009
Last Update Date	:	01/05/2009

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