Provider Demographics
NPI:1063619062
Name:AMIRI, BERTRAM B (DDS)
Entity type:Individual
Prefix:
First Name:BERTRAM
Middle Name:B
Last Name:AMIRI
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 1:3500 E WHITTIER BLVD
Mailing Address - Street 2:#101
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90023
Mailing Address - Country:US
Mailing Address - Phone:323-264-8834
Mailing Address - Fax:323-264-0885
Practice Address - Street 1:3500 E WHITTIER BLVD
Practice Address - Street 2:#101
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90023
Practice Address - Country:US
Practice Address - Phone:323-264-8834
Practice Address - Fax:323-264-0885
Is Sole Proprietor?:No
Enumeration Date:2007-07-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB3458601122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist