=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245503754
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JABEEN MAH KHAN DDS, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2012
-----------------------------------------------------
Last Update Date | 02/14/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 643 W MANCHESTER AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90044-5718
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-753-1411
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 643 W MANCHESTER AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90044-5718
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. JABEEN MAH KHAN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 323-753-1411
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 55705
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------