Healthcare Provider Details

I. General information

NPI: 1245518810
Provider Name (Legal Business Name): ELYSA RACHEL KAHAN DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2011
Last Update Date: 03/31/2023
Certification Date: 03/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18372 CLARK STREET SUITE 201
TARZANA CA
91356
US

IV. Provider business mailing address

18372 CLARK STREET SUITE 201
TARZANA CA
91356
US

V. Phone/Fax

Practice location:
  • Phone: 818-578-8782
  • Fax:
Mailing address:
  • Phone: 818-578-8782
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number63683
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: