MEDICARE: BASHAR KOMOC DDS, INC.

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	42317	CA

General Provider Information

NPI Number	:	1114181260
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BASHAR KOMOC DDS, INC.

Provider Business Mailing Address
First Line	:	3318 E ANAHEIM ST
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90804-4025
Country	:	US
Telephone Number	:	562-986-5570
Fax Number	:	562-986-9791

Provider Business Practice Location Address
First Line	:	3318 E ANAHEIM ST
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90804-4025
Country	:	US
Telephone Number	:	562-986-5570
Fax Number	:	562-986-9791

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. BASHAR KOMOC
Credential	:	DDS
Telephone Number	:	562-986-5570

Provider Enumeration Date	:	07/17/2008
Last Update Date	:	07/17/2008

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