Healthcare Provider Details

I. General information

NPI: 1720804768
Provider Name (Legal Business Name): RAMESH KHORSAND
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/25/2024
Last Update Date: 11/25/2024
Certification Date: 11/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15215 MAGNOLIA BLVD UNIT 126
SHERMAN OAKS CA
91403-1120
US

IV. Provider business mailing address

15215 MAGNOLIA BLVD UNIT 126
SHERMAN OAKS CA
91403-1120
US

V. Phone/Fax

Practice location:
  • Phone: 818-469-9154
  • Fax:
Mailing address:
  • Phone: 818-469-9154
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number111058
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: