=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124241575
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AL SHYSTE MANESH DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/11/2007
-----------------------------------------------------
Last Update Date | 11/20/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24953 PASEO DE VALENCIA STE 13C
-----------------------------------------------------
City | LAGUNA HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92653-4344
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-600-7123
-----------------------------------------------------
Fax | 949-364-2870
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 26800 CROWN VALLEY PARKWAY SUITE 425
-----------------------------------------------------
City | MISSION VIEJO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92691
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-364-2935
-----------------------------------------------------
Fax | 949-364-2870
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 48376
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | 48376
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------