Healthcare Provider Details

I. General information

NPI: 1376947200
Provider Name (Legal Business Name): ELYSA R KAHAN DMD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2014
Last Update Date: 10/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18372 CLARK ST STE 201
TARZANA CA
91356-3550
US

IV. Provider business mailing address

18372 CLARK ST STE 201
TARZANA CA
91356-3550
US

V. Phone/Fax

Practice location:
  • Phone: 818-996-5100
  • Fax:
Mailing address:
  • Phone: 818-996-5100
  • 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: DR. STANLEY EDWARD KAHAN
Title or Position: OFFICER
Credential: M.D.
Phone: 310-728-9581