MEDICARE: SINA EDALAT DENTAL GROUP, 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

General Provider Information

NPI Number	:	1225793458
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SINA EDALAT DENTAL GROUP, INC

Provider Business Mailing Address
First Line	:	11420 AMANDA DR
Second Line	:
City	:	STUDIO CITY
State	:	CA
Zip	:	91604-4141
Country	:	US
Telephone Number	:	818-934-3666
Fax Number	:

Provider Business Practice Location Address
First Line	:	1739 COLORADO BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90041-1348
Country	:	US
Telephone Number	:	323-344-0682
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. SINA EDALAT
Credential	:	DDS
Telephone Number	:	323-344-0682

Provider Enumeration Date	:	11/02/2021
Last Update Date	:	03/15/2023

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