Provider Demographics
NPI:1568710333
Name:A SABBAGH-FARD DDS & P. MASTOUR DDS INC
Entity Type:Organization
Organization Name:A SABBAGH-FARD DDS & P. MASTOUR DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PEDRAM
Authorized Official - Middle Name:E
Authorized Official - Last Name:MASTOUR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-390-6212
Mailing Address - Street 1:5620 SAWTELLE BLVD
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90230-5508
Mailing Address - Country:US
Mailing Address - Phone:310-390-6212
Mailing Address - Fax:310-390-6215
Practice Address - Street 1:5620 SAWTELLE BLVD
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90230-5508
Practice Address - Country:US
Practice Address - Phone:310-390-6212
Practice Address - Fax:310-390-6215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA122300000X, 1223P0300X, 1223S0112X, 305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
No305R00000XManaged Care OrganizationsPreferred Provider OrganizationGroup - Single Specialty