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General NPI Number Information
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NPI Number | 1548757347
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Entity Type | Organization
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Legal Business Name | LISA KEDERIAN DDS, INC.
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Dates
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Enumeration Date | 04/17/2018
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Last Update Date | 04/17/2018
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Provider Practice Location Address
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Address Line | 11500 W OLYMPIC BLVD STE 604
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City | LOS ANGELES
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State | CA
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Zip | 90064-2300
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Country | US
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Telephone | 424-901-0701
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Fax |
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Provider Business Mailing Address
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Address Line | 11500 W OLYMPIC BLVD STE 604
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City | LOS ANGELES
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State | CA
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Zip | 90064-2300
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Country | US
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Telephone | 424-901-0701
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Fax |
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | NIKKI OTKOSOVA
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Credential |
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Telephone | 424-901-0701
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | B54586
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License Number State | CA
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