MEDICARE: DR. KAMRAN GHOREYSHI DDS

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	44481	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	B4445101	OTHER	CA	DENTICAL

General Provider Information

NPI Number	:	1265407928
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KAMRAN GHOREYSHI DDS

Provider Business Mailing Address
First Line	:	408 E 3RD ST
Second Line	:	SUITE C
City	:	CALEXICO
State	:	CA
Zip	:	92231
Country	:	US
Telephone Number	:	760-357-9000
Fax Number	:	760-357-9009

Provider Business Practice Location Address
First Line	:	408 E 3RD ST
Second Line	:	SUITE C
City	:	CALEXICO
State	:	CA
Zip	:	92231
Country	:	US
Telephone Number	:	760-357-9000
Fax Number	:	760-357-9009

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

Provider Enumeration Date	:	02/17/2006
Last Update Date	:	12/14/2007

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