Healthcare Provider Details

I. General information

NPI: 1538585294
Provider Name (Legal Business Name): LYLA BOUSTANI D.D.S. DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2014
Last Update Date: 03/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12626 RIVERSIDE DR STE 403
STUDIO CITY CA
91607-3420
US

IV. Provider business mailing address

12626 RIVERSIDE DR STE 403
STUDIO CITY CA
91607-3420
US

V. Phone/Fax

Practice location:
  • Phone: 818-980-0998
  • Fax: 818-980-0991
Mailing address:
  • Phone: 818-980-0998
  • Fax: 818-980-0991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State

VIII. Authorized Official

Name: DR. LYLA BOUSTANI
Title or Position: PRESIDENT
Credential: DDS
Phone: 818-980-0998