MEDICARE: DR. SALLY YOUSEFI DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	54912	CA

General Provider Information

NPI Number	:	1316186620
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SALLY YOUSEFI DDS

Provider Business Mailing Address
First Line	:	107 N SWALL DR APT 203
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90048-3029
Country	:	US
Telephone Number	:	818-515-4012
Fax Number	:

Provider Business Practice Location Address
First Line	:	500 E OLIVE AVE STE 430
Second Line	:
City	:	BURBANK
State	:	CA
Zip	:	91501-2171
Country	:	US
Telephone Number	:	818-515-4012
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/10/2009
Last Update Date	:	02/16/2009

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