MEDICARE: FARZADKOHANBASH INC. DBA UNITEDDENTALOFFICE

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	41441	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1992914675	OTHER	CA	TYPE1 INDIVIDUAL NPI

General Provider Information

NPI Number	:	1942526157
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FARZADKOHANBASH INC. DBA UNITEDDENTALOFFICE

Provider Business Mailing Address
First Line	:	1720 S WESTERN AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90006-5804
Country	:	US
Telephone Number	:	323-733-0570
Fax Number	:	323-733-0540

Provider Business Practice Location Address
First Line	:	1720 S WESTERN AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90006-5804
Country	:	US
Telephone Number	:	323-733-0570
Fax Number	:	323-733-0540

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. FARZAD KOHANBASH
Credential	:	DDS
Telephone Number	:	323-733-0570

Provider Enumeration Date	:	04/13/2010
Last Update Date	:	04/13/2010

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