Healthcare Provider Details

I. General information

NPI: 1932667631
Provider Name (Legal Business Name): BAMSHAD DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2019
Last Update Date: 03/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19231 VICTORY BLVD STE 458
RESEDA CA
91335-6368
US

IV. Provider business mailing address

19231 VICTORY BLVD STE 458
RESEDA CA
91335-6368
US

V. Phone/Fax

Practice location:
  • Phone: 818-345-6477
  • Fax: 818-345-1509
Mailing address:
  • Phone: 818-345-6477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: DR. KEYVAN BAMSHAD
Title or Position: OWNER/ DENTIST
Credential: DDS
Phone: 818-345-6477