MEDICARE: AFSANEH S DADSERESHT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	124Q00000X	Dental Hygienist	18833	CA

General Provider Information

NPI Number	:	1023401734
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AFSANEH S DADSERESHT

Provider Business Mailing Address
First Line	:	1115 S ELM DR APT 203
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90035-1132
Country	:	US
Telephone Number	:	323-568-9593
Fax Number	:

Provider Business Practice Location Address
First Line	:	1115 S ELM DR APT 203
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90035-1132
Country	:	US
Telephone Number	:	323-568-9593
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/05/2015
Last Update Date	:	03/05/2015

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Directions to “ AFSANEH S DADSERESHT ” Practice Location

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