Provider Demographics
NPI:1164949111
Name:SHAYESTEH KHORRAM, PEGAH (DDS)
Entity Type:Individual
Prefix:
First Name:PEGAH
Middle Name:
Last Name:SHAYESTEH KHORRAM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6846 RESEDA BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-8512
Mailing Address - Country:US
Mailing Address - Phone:818-578-5170
Mailing Address - Fax:
Practice Address - Street 1:22233 BUENA VENTURA ST
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91364-5007
Practice Address - Country:US
Practice Address - Phone:818-624-4846
Practice Address - Fax:818-624-4846
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-29
Last Update Date:2018-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1019651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty