Healthcare Provider Details

I. General information

NPI: 1467531889
Provider Name (Legal Business Name): MASOOD IMANUEL DMD A DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2006
Last Update Date: 06/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14150 VAN NUYS BLVD SUITE 105
ARLETA CA
91331-5114
US

IV. Provider business mailing address

14150 VAN NUYS BLVD SUITE 105
ARLETA CA
91331-5114
US

V. Phone/Fax

Practice location:
  • Phone: 818-899-9999
  • Fax: 818-897-0859
Mailing address:
  • Phone: 818-899-9999
  • Fax: 818-897-0859

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number39418
License Number StateCA

VIII. Authorized Official

Name: DR. SIMON MASOOD IMANUEL
Title or Position: PRESIDENT
Credential: DMD
Phone: 818-899-9999