Provider Demographics
NPI:1336291517
Name:BENJI BEHROOZAN, EHTERAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:EHTERAM
Middle Name:
Last Name:BENJI BEHROOZAN
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 1:2221 LINCOLN BLVD
Mailing Address - Street 2:#200
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-1320
Mailing Address - Country:US
Mailing Address - Phone:310-399-1100
Mailing Address - Fax:310-664-8901
Practice Address - Street 1:2221 LINCOLN BLVD
Practice Address - Street 2:#200
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90405-1320
Practice Address - Country:US
Practice Address - Phone:310-399-1100
Practice Address - Fax:310-664-8901
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA315681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD31568OtherDENTAL PROVIDER NUMBER WI