MEDICARE: PARHAM MANSOURI

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	1223E0200X	Endodontics	53085	CA

General Provider Information

NPI Number	:	1982740213
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PARHAM MANSOURI

Provider Business Mailing Address
First Line	:	12509 OXNARD ST
Second Line	:	201
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91606-4440
Country	:	US
Telephone Number	:	818-285-5757
Fax Number	:	818-257-5760

Provider Business Practice Location Address
First Line	:	12509 OXNARD ST
Second Line	:	201
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91606-4467
Country	:	US
Telephone Number	:	818-285-5757
Fax Number	:	818-257-5760

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

Provider Enumeration Date	:	01/30/2007
Last Update Date	:	07/08/2007

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