=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205026739
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JALEH JASMIN GANDJEH, RDHAP, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/31/2007
-----------------------------------------------------
Last Update Date | 07/31/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18210 SHERMAN WAY SUITE 207
-----------------------------------------------------
City | RESEDA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91335-4554
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-344-1121
-----------------------------------------------------
Fax | 818-344-1131
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21157 LASSEN ST UNIT 2
-----------------------------------------------------
City | CHATSWORTH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91311-6813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-344-1121
-----------------------------------------------------
Fax | 818-344-1131
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MS. JALEH JASMIN GANDJEH
-----------------------------------------------------
Credential | RDHAP
-----------------------------------------------------
Telephone | 818-344-1121
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------