=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851581748
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR YURY GEYLIKMAN PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2007
-----------------------------------------------------
Last Update Date | 09/12/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 928 N SAN FERNANDO BLVD
-----------------------------------------------------
City | BURBANK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91504-4350
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-656-9111
-----------------------------------------------------
Fax | 323-650-9669
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3940 LAUREL CANYON BLVD #388
-----------------------------------------------------
City | STUDIO CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91604-3709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-656-9111
-----------------------------------------------------
Fax | 323-650-9669
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. YURY GEYLIKMAN
-----------------------------------------------------
Credential | DMD; PHD
-----------------------------------------------------
Telephone | 323-656-9111
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 41255
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------