Provider Demographics
NPI:1891110219
Name:BEHNAM B. BASERI, DDS. INC.
Entity Type:Organization
Organization Name:BEHNAM B. BASERI, DDS. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BEHNAM
Authorized Official - Middle Name:BERNARD
Authorized Official - Last Name:BASERI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-877-4767
Mailing Address - Street 1:269 S BEVERLY DR
Mailing Address - Street 2:108
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90212-3851
Mailing Address - Country:US
Mailing Address - Phone:424-222-9202
Mailing Address - Fax:
Practice Address - Street 1:269 S BEVERLY DR
Practice Address - Street 2:108
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90212-3851
Practice Address - Country:US
Practice Address - Phone:424-222-9202
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-21
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA62519122300000X, 1223D0001X, 1223E0200X, 1223G0001X, 1223P0221X, 1223P0300X, 1223P0700X, 1223S0112X, 1223X0400X, 124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223D0001XDental ProvidersDentistDental Public HealthGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty