MEDICARE: DR. LISA B. KEDERIAN 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	54586	CA

General Provider Information

NPI Number	:	1215000492
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LISA B. KEDERIAN D.D.S.

Provider Business Mailing Address
First Line	:	11500 W OLYMPIC BLVD STE 326
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90064-1527
Country	:	US
Telephone Number	:	424-901-0701
Fax Number	:

Provider Business Practice Location Address
First Line	:	11500 W OLYMPIC BLVD STE 326
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90064-1527
Country	:	US
Telephone Number	:	424-901-0701
Fax Number	:

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

Provider Enumeration Date	:	11/16/2006
Last Update Date	:	07/01/2010

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