Healthcare Provider Details

I. General information

NPI: 1053529586
Provider Name (Legal Business Name): NIKNAM & KHANIAN DENTAL PRACTICE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 06/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4023 W AVENUE L
LANCASTER CA
93536-4213
US

IV. Provider business mailing address

4023 W AVENUE L
LANCASTER CA
93536-4213
US

V. Phone/Fax

Practice location:
  • Phone: 661-722-7722
  • Fax: 661-722-7726
Mailing address:
  • Phone: 661-722-7722
  • Fax: 661-722-7726

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MS. ANNETTE CAMILLE JOLICOEUR
Title or Position: OFFICE MANAGER
Credential: R.D.A
Phone: 661-722-7722