Provider Demographics
NPI:1285318360
Name:PEZESHKI, BEHNOOSH
Entity type:Individual
Prefix:
First Name:BEHNOOSH
Middle Name:
Last Name:PEZESHKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:258 N BOWLING GREEN WAY
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-2816
Mailing Address - Country:US
Mailing Address - Phone:310-909-3638
Mailing Address - Fax:
Practice Address - Street 1:258 N BOWLING GREEN WAY
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-2816
Practice Address - Country:US
Practice Address - Phone:310-909-3638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-09
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA539351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice