Healthcare Provider Details

I. General information

NPI: 1861510745
Provider Name (Legal Business Name): NAZLY KHORSANDI DDS.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 04/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16500 VENTURA BLVD. SUITE 150
ENCINO CA
91436
US

IV. Provider business mailing address

626 11TH ST
SANTA MONICA CA
90402
US

V. Phone/Fax

Practice location:
  • Phone: 818-907-1818
  • Fax: 310-899-5111
Mailing address:
  • Phone: 310-435-8184
  • Fax: 310-899-5111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number40251
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number40251
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: