=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528369477
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BEATA PEZESHKI DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2010
-----------------------------------------------------
Last Update Date | 09/18/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3467 ARDSLEY PL
-----------------------------------------------------
City | ENCINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91436-4023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-429-2536
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5363 BALBOA BLVD #325
-----------------------------------------------------
City | ENCINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91316-2805
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-788-1181
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 59989
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------