Healthcare Provider Details

I. General information

NPI: 1366982399
Provider Name (Legal Business Name): ANNIE KHOMMARATH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2017
Last Update Date: 02/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1846 AMARGOSA DR
PALMDALE CA
93551-5114
US

IV. Provider business mailing address

1846 AMARGOSA DR
PALMDALE CA
93551-5114
US

V. Phone/Fax

Practice location:
  • Phone: 818-645-6069
  • Fax:
Mailing address:
  • Phone: 818-645-6069
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number79331
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: