Healthcare Provider Details

I. General information

NPI: 1376695825
Provider Name (Legal Business Name): HAMID REZA IMANKHAN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13100 PONTOON PL
LOS ANGELES CA
90049-3634
US

IV. Provider business mailing address

2311 VENTURA BLVD 104
WOODLAND HILLS CA
91364
US

V. Phone/Fax

Practice location:
  • Phone: 310-395-6084
  • Fax:
Mailing address:
  • Phone: 818-225-7768
  • Fax: 818-225-1138

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number46073
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: