MEDICARE: KHASHAYAR KHODADADI D.D.S

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	1223G0001X	General Practice Dentistry	43026	CA

General Provider Information

NPI Number	:	1083743926
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KHASHAYAR KHODADADI D.D.S

Provider Business Mailing Address
First Line	:	11900 S. AVALON BLVD.
Second Line	:	SUITE 101
City	:	LOS ANGELES
State	:	CA
Zip	:	90061-2837
Country	:	US
Telephone Number	:	323-834-0100
Fax Number	:	323-834-0101

Provider Business Practice Location Address
First Line	:	11900 S. AVALON BLVD.
Second Line	:	SUITE 101
City	:	LOS ANGELES
State	:	CA
Zip	:	90061-2837
Country	:	US
Telephone Number	:	323-834-0100
Fax Number	:	323-834-0101

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

Provider Enumeration Date	:	03/05/2007
Last Update Date	:	07/08/2007

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