Healthcare Provider Details

I. General information

NPI: 1700536810
Provider Name (Legal Business Name): MAKAN TARZANA DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2022
Last Update Date: 03/24/2022
Certification Date: 03/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18372 CLARK ST STE 224
TARZANA CA
91356-3559
US

IV. Provider business mailing address

1908 RUE LE CHARLENE
RANCHO PALOS VERDES CA
90275-6372
US

V. Phone/Fax

Practice location:
  • Phone: 818-996-1200
  • Fax:
Mailing address:
  • Phone: 310-872-8681
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: SIRISH MAKAN
Title or Position: OFFICER
Credential: D.D.S.
Phone: 310-872-8681