=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407489164
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MEHRNOOSH AKHAVAN DDS, MS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2020
-----------------------------------------------------
Last Update Date | 12/17/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18919 VENTURA BLVD STE B
-----------------------------------------------------
City | TARZANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91356-3211
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-345-9601
-----------------------------------------------------
Fax | 818-757-8901
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18919 VENTURA BLVD STE B
-----------------------------------------------------
City | TARZANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91356-3211
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-345-9601
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 38020
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------