Provider Demographics
NPI:1750437109
Name:KHAKSHOOY, SIAMAK (DDS)
Entity type:Individual
Prefix:
First Name:SIAMAK
Middle Name:
Last Name:KHAKSHOOY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 N WETHERLY DR
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211-1813
Mailing Address - Country:US
Mailing Address - Phone:310-925-9991
Mailing Address - Fax:
Practice Address - Street 1:3451 W CENTURY BLVD STE B1
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90303-1228
Practice Address - Country:US
Practice Address - Phone:310-330-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54539122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist