Provider Demographics
NPI:1194931618
Name:BROUMANDI, DIANA (DDS)
Entity type:Individual
Prefix:DR
First Name:DIANA
Middle Name:
Last Name:BROUMANDI
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 1:11645 WILSHIRE BLVD.
Mailing Address - Street 2:#745
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025
Mailing Address - Country:US
Mailing Address - Phone:310-696-0100
Mailing Address - Fax:310-696-0700
Practice Address - Street 1:11645 WILSHIRE BLVD.
Practice Address - Street 2:#745
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025
Practice Address - Country:US
Practice Address - Phone:310-696-0100
Practice Address - Fax:310-395-2288
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA470461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice