MEDICARE: CHAMKASEM, 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	50043	CA

General Provider Information

NPI Number	:	1255357711
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHAMKASEM, DDS, INC.

Provider Business Mailing Address
First Line	:	17542 IRVINE BLVD
Second Line	:	SUITE D
City	:	TUSTIN
State	:	CA
Zip	:	92780-3155
Country	:	US
Telephone Number	:	714-573-1224
Fax Number	:

Provider Business Practice Location Address
First Line	:	17542 IRVINE BLVD
Second Line	:	SUITE D
City	:	TUSTIN
State	:	CA
Zip	:	92780-3155
Country	:	US
Telephone Number	:	714-573-1224
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DR. PISHYA CHAMKASEM
Credential	:	DDS
Telephone Number	:	714-573-1224

Provider Enumeration Date	:	07/15/2006
Last Update Date	:	03/24/2008

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