Healthcare Provider Details

I. General information

NPI: 1366751364
Provider Name (Legal Business Name): MANDANA KHALATBARI DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2010
Last Update Date: 10/07/2025
Certification Date: 10/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14119 PIONEER BLVD
NORWALK CA
90650-3925
US

IV. Provider business mailing address

10 MANDRAKE WAY
IRVINE CA
92612-2713
US

V. Phone/Fax

Practice location:
  • Phone: 562-929-2383
  • Fax:
Mailing address:
  • Phone: 646-284-4746
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDDS101231
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: