Healthcare Provider Details

I. General information

NPI: 1508045790
Provider Name (Legal Business Name): TMJ AND SLEEP THERAPY CENTRE OF CONEJO VALLEY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2007
Last Update Date: 07/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

558 SAINT CHARLES DR # 201
THOUSAND OAKS CA
91360-3903
US

IV. Provider business mailing address

558 SAINT CHARLES DR # 201
THOUSAND OAKS CA
91360-3903
US

V. Phone/Fax

Practice location:
  • Phone: 805-496-5700
  • Fax: 805-496-5719
Mailing address:
  • Phone: 805-496-5700
  • Fax: 805-496-5719

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDDS48020
License Number StateCA

VIII. Authorized Official

Name: DR. DAVID ESMAIL SHIRAZI
Title or Position: DIRECTOR
Credential: D.D.S.
Phone: 805-496-5700