Provider Demographics
NPI:1255021804
Name:HEDVAT, SIMON (DMD)
Entity type:Individual
Prefix:
First Name:SIMON
Middle Name:
Last Name:HEDVAT
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:339 N OAKHURST DR APT 203
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210-4162
Mailing Address - Country:US
Mailing Address - Phone:310-990-9790
Mailing Address - Fax:
Practice Address - Street 1:1260 15TH ST STE 703
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-1142
Practice Address - Country:US
Practice Address - Phone:310-393-8284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-08
Last Update Date:2025-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA110189122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program