Healthcare Provider Details

I. General information

NPI: 1669639548
Provider Name (Legal Business Name): PAYMAN KAKOLI DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2008
Last Update Date: 03/28/2024
Certification Date: 03/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16133 VENTURA BLVD STE 1100A
ENCINO CA
91436-2415
US

IV. Provider business mailing address

18375 VENTURA BLVD # 727
TARZANA CA
91356-4218
US

V. Phone/Fax

Practice location:
  • Phone: 443-414-8430
  • Fax:
Mailing address:
  • Phone: 443-414-8430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number56151
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: