Provider Demographics
NPI:1407052814
Name:JEDIAN, SHAHROKH MOSHE (DDS)
Entity Type:Individual
Prefix:DR
First Name:SHAHROKH
Middle Name:MOSHE
Last Name:JEDIAN
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 1:1710 GRANVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-7368
Mailing Address - Country:US
Mailing Address - Phone:310-404-6476
Mailing Address - Fax:
Practice Address - Street 1:10318 ROSECRANS AVE
Practice Address - Street 2:
Practice Address - City:BELLFLOWER
Practice Address - State:CA
Practice Address - Zip Code:90706-2702
Practice Address - Country:US
Practice Address - Phone:562-925-3765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA524031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice