Provider Demographics
NPI:1760020598
Name:EHTESSABIAN, KEVIN M (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:M
Last Name:EHTESSABIAN
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 1:2725 VIA VICTORIA
Mailing Address - Street 2:
Mailing Address - City:PALOS VERDES ESTATES
Mailing Address - State:CA
Mailing Address - Zip Code:90274-4475
Mailing Address - Country:US
Mailing Address - Phone:310-308-5996
Mailing Address - Fax:
Practice Address - Street 1:2725 VIA VICTORIA
Practice Address - Street 2:
Practice Address - City:PALOS VERDES ESTATES
Practice Address - State:CA
Practice Address - Zip Code:90274-4475
Practice Address - Country:US
Practice Address - Phone:310-308-5996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-11
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA104525122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist