Healthcare Provider Details

I. General information

NPI: 1255427373
Provider Name (Legal Business Name): EDMOND TASH D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 09/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6200 WILSHIRE BLVD SUITE 1409
LOS ANGELES CA
90048-5801
US

IV. Provider business mailing address

6200 WILSHIRE BLVD SUITE 1409
LOS ANGELES CA
90048-5801
US

V. Phone/Fax

Practice location:
  • Phone: 323-939-9944
  • Fax:
Mailing address:
  • Phone: 323-939-9944
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number47422
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: