Provider Demographics
NPI:1225170186
Name:PAKRAVAN, FAIRD
Entity Type:Individual
Prefix:
First Name:FAIRD
Middle Name:
Last Name:PAKRAVAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12121 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 1111
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-1123
Mailing Address - Country:US
Mailing Address - Phone:310-820-9933
Mailing Address - Fax:310-820-0408
Practice Address - Street 1:12121 WILSHIRE BLVD
Practice Address - Street 2:SUITE 1111
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-1123
Practice Address - Country:US
Practice Address - Phone:310-820-9933
Practice Address - Fax:310-820-0408
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA398621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice