Provider Demographics
NPI:1740278662
Name:VATAN, OMID (DDS)
Entity type:Individual
Prefix:DR
First Name:OMID
Middle Name:
Last Name:VATAN
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 1:8540 S SEPULVEDA BLVD STE 108
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-3818
Mailing Address - Country:US
Mailing Address - Phone:310-906-1300
Mailing Address - Fax:424-206-0662
Practice Address - Street 1:8540 S SEPULVEDA BLVD STE 108
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-3818
Practice Address - Country:US
Practice Address - Phone:310-906-1300
Practice Address - Fax:424-206-0662
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2025-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49259122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG9279901Medicaid