=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376947200
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELYSA R KAHAN DMD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/21/2014
-----------------------------------------------------
Last Update Date | 10/21/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18372 CLARK ST STE 201
-----------------------------------------------------
City | TARZANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91356-3550
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-996-5100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18372 CLARK ST STE 201
-----------------------------------------------------
City | TARZANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91356-3550
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-996-5100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICER
-----------------------------------------------------
Name | DR. STANLEY EDWARD KAHAN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 310-728-9581
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 63683
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------