Provider Demographics
NPI:1205974318
Name:SABETI, SHOHREH
Entity type:Individual
Prefix:DR
First Name:SHOHREH
Middle Name:
Last Name:SABETI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SABETI
Other - Middle Name:COSMETIC
Other - Last Name:DENTAL PRACTICE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:269 S BEVERLY DR
Mailing Address - Street 2:#644
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90212-3851
Mailing Address - Country:US
Mailing Address - Phone:310-770-0720
Mailing Address - Fax:
Practice Address - Street 1:9201 W SUNSET BLVD STE 517
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90069-3706
Practice Address - Country:US
Practice Address - Phone:310-707-1577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550961223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD55096Medicaid