=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568834232
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | M. SALEH KHOLAKI D.D.S, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/21/2015
-----------------------------------------------------
Last Update Date | 10/21/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 513 E LIME AVE STE 204
-----------------------------------------------------
City | MONROVIA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91016-2984
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-301-4220
-----------------------------------------------------
Fax | 626-301-4223
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 513 E LIME AVE STE 204
-----------------------------------------------------
City | MONROVIA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91016-2984
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-301-4220
-----------------------------------------------------
Fax | 626-301-4223
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MOHAMAD SALEH KHOLAKI
-----------------------------------------------------
Credential | D.D.S
-----------------------------------------------------
Telephone | 626-301-4220
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DA033301
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------