=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902933831
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EMMANUEL B. KANDKHOROV DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2007
-----------------------------------------------------
Last Update Date | 01/08/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 33 CREEK RD STE A-150
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92604-4791
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-825-7799
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 33 CREEK RD STE A-150
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92604-4791
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-825-7799
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 50617
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------