MEDICARE: MANIJEH AFSHAR-EBRAHIMI

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	122300000X	Dentist	55822	CA

General Provider Information

NPI Number	:	1083933956
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MANIJEH AFSHAR-EBRAHIMI

Provider Business Mailing Address
First Line	:	133 S SWALL DR
Second Line	:	#3
City	:	LOS ANGELES
State	:	CA
Zip	:	90048-3032
Country	:	US
Telephone Number	:	818-425-7147
Fax Number	:

Provider Business Practice Location Address
First Line	:	133 S SWALL DR
Second Line	:	#3
City	:	LOS ANGELES
State	:	CA
Zip	:	90048-3032
Country	:	US
Telephone Number	:	818-425-7147
Fax Number	:

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

Provider Enumeration Date	:	05/18/2010
Last Update Date	:	05/18/2010

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Directions to “ MANIJEH AFSHAR-EBRAHIMI ” Practice Location

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