Provider Demographics
NPI:1003999707
Name:KBOUDI, JASON V (DDS)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:V
Last Name:KBOUDI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8641 WILSHIRE BLVD STE 205
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211-2920
Mailing Address - Country:US
Mailing Address - Phone:310-626-1212
Mailing Address - Fax:310-626-0111
Practice Address - Street 1:8641 WILSHIRE BLVD STE 205
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-2920
Practice Address - Country:US
Practice Address - Phone:310-626-1212
Practice Address - Fax:310-626-0111
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX133221223G0001X
TX194851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX803551OtherUNITED CONCORDIA
TX82D611OtherBLUE CROSS BLUE SHIELD