=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124140751
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THOUSAND OAKS CHILDRENS DENTAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/04/2007
-----------------------------------------------------
Last Update Date | 02/04/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 61 LONG CT SUITE 202
-----------------------------------------------------
City | THOUSAND OAKS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91360
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-497-3797
-----------------------------------------------------
Fax | 805-371-1121
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 61 LONG CT SUITE 202
-----------------------------------------------------
City | THOUSAND OAKS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91360
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-497-3797
-----------------------------------------------------
Fax | 805-371-1121
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PARTNER
-----------------------------------------------------
Name | MR. AHSAN S RAZA
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 805-497-3797
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 036029
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------