Provider Demographics
NPI:1093298671
Name:BASTI, SEPIDEH A (DDS)
Entity type:Individual
Prefix:DR
First Name:SEPIDEH
Middle Name:A
Last Name:BASTI
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 1:11642 KIOWA AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-6213
Mailing Address - Country:US
Mailing Address - Phone:310-775-3033
Mailing Address - Fax:
Practice Address - Street 1:11642 KIOWA AVE APT 1
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-6213
Practice Address - Country:US
Practice Address - Phone:310-775-3033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-10
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103104122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA103104Medicaid