Provider Demographics
NPI:1093865107
Name:EMMANUEL, FRED FERAYDOON (DDS)
Entity Type:Individual
Prefix:MR
First Name:FRED
Middle Name:FERAYDOON
Last Name:EMMANUEL
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 1:9301 WILSHIRE BLVD
Mailing Address - Street 2:#407
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210
Mailing Address - Country:US
Mailing Address - Phone:310-278-3666
Mailing Address - Fax:310-278-6495
Practice Address - Street 1:9301 WILSHIRE BLVD
Practice Address - Street 2:#407
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210
Practice Address - Country:US
Practice Address - Phone:310-278-3666
Practice Address - Fax:310-278-6495
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30646122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist