Healthcare Provider Details

I. General information

NPI: 1003953126
Provider Name (Legal Business Name): KHOSHROZEH DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 11/16/2020
Certification Date: 11/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4080 WHITTIER BLVD
LOS ANGELES CA
90023-2527
US

IV. Provider business mailing address

4080 WHITTIER BLVD
LOS ANGELES CA
90023-2527
US

V. Phone/Fax

Practice location:
  • Phone: 323-582-4744
  • Fax: 323-582-3101
Mailing address:
  • Phone: 323-582-4474
  • Fax: 323-582-3101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number49906
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number43515
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number49909
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number53064
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number53901
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number30624
License Number StateCA
# 7
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number73479
License Number StateCA
# 8
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberA91274
License Number StateCA
# 9
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number20482
License Number StateCA
# 10
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number43990
License Number StateCA

VIII. Authorized Official

Name: DR. MEHRDAD KHOSHROZEH
Title or Position: OWNER/ PRESIDENT
Credential:
Phone: 310-386-8246