Provider Demographics
NPI:1841745627
Name:PRESTIGE DENTAL SPA OF BEVERLY HILLS
Entity Type:Organization
Organization Name:PRESTIGE DENTAL SPA OF BEVERLY HILLS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:OMID
Authorized Official - Last Name:COHANIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-288-2121
Mailing Address - Street 1:9150 WILSHIRE BLVD STE 242
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90212-3429
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9150 WILSHIRE BLVD STE 242
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90212-3429
Practice Address - Country:US
Practice Address - Phone:310-288-2121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-22
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41908122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA41908OtherMEDICAL, DENTICAL, METDENTAL, AETNA, AMERITAS, ANTHEM BLUE CROSS, ASSURANT HEALT