Provider Demographics
NPI:1003191123
Name:DRS SIAMAK KHAKSHOOY AND SOHEIL VAHEDI DDS INC
Entity Type:Organization
Organization Name:DRS SIAMAK KHAKSHOOY AND SOHEIL VAHEDI DDS INC
Other - Org Name:AESTHETICA DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SOHEIL
Authorized Official - Middle Name:
Authorized Official - Last Name:VAHEDI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-775-5225
Mailing Address - Street 1:3451 W CENTURY BLVD STE B1
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90303-1228
Mailing Address - Country:US
Mailing Address - Phone:310-330-9000
Mailing Address - Fax:310-330-9303
Practice Address - Street 1:3451 W CENTURY BLVD STE B1
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90303-1228
Practice Address - Country:US
Practice Address - Phone:310-330-9000
Practice Address - Fax:310-330-9303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-20
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA547351223G0001X
CA545391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1306982335OtherPROVIDER
CA1750437109OtherPROVIDER