Provider Demographics
NPI:1699220608
Name:BASERI, BEHNAM BERNARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:BEHNAM
Middle Name:BERNARD
Last Name:BASERI
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 1:6221 WILSHIRE BLVD.
Mailing Address - Street 2:517
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048
Mailing Address - Country:US
Mailing Address - Phone:323-413-2903
Mailing Address - Fax:323-879-6639
Practice Address - Street 1:6221 WILSHIRE BLVD
Practice Address - Street 2:517
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5201
Practice Address - Country:US
Practice Address - Phone:323-413-2903
Practice Address - Fax:323-879-6639
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-19
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA62519122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist