Provider Demographics
NPI:1205612355
Name:KHAZAEI, PEGAH (DDS)
Entity type:Individual
Prefix:DR
First Name:PEGAH
Middle Name:
Last Name:KHAZAEI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3602 KEYSTONE AVE APT 7
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034-5621
Mailing Address - Country:US
Mailing Address - Phone:747-250-2319
Mailing Address - Fax:
Practice Address - Street 1:11600 WILSHIRE BLVD STE 504
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-1788
Practice Address - Country:US
Practice Address - Phone:310-231-5100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-05
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA109216122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist