MEDICARE: DR. KEITH ROSHANALI MERCHANT D.D.S.

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	1223G0001X	General Practice Dentistry	5489	LA
2	1223G0001X	General Practice Dentistry	55794	CA

General Provider Information

NPI Number	:	1346227303
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KEITH ROSHANALI MERCHANT D.D.S.

Provider Business Mailing Address
First Line	:	917 YOSEMITE DR
Second Line	:
City	:	CHULA VISTA
State	:	CA
Zip	:	91914-3610
Country	:	US
Telephone Number	:	619-941-1266
Fax Number	:

Provider Business Practice Location Address
First Line	:	1879 PLATTE RIVER LN
Second Line	:	#2
City	:	CHULA VISTA
State	:	CA
Zip	:	91913-1698
Country	:	US
Telephone Number	:	619-941-1266
Fax Number	:

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

Provider Enumeration Date	:	12/29/2005
Last Update Date	:	02/25/2008

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