Healthcare Provider Details

I. General information

NPI: 1245503754
Provider Name (Legal Business Name): JABEEN MAH KHAN DDS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2012
Last Update Date: 02/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

643 W MANCHESTER AVE
LOS ANGELES CA
90044-5718
US

IV. Provider business mailing address

643 W MANCHESTER AVE
LOS ANGELES CA
90044-5718
US

V. Phone/Fax

Practice location:
  • Phone: 323-753-1411
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number55705
License Number StateCA

VIII. Authorized Official

Name: DR. JABEEN MAH KHAN
Title or Position: DENTIST
Credential: DDS
Phone: 323-753-1411