MEDICARE: DR. KAMRAN DASTOURY M.D.

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	204E00000X	Oral & Maxillofacial Surgery (D.M.D.)	101382	CA
2	261QA1903X	Ambulatory Surgical Clinic/Center	A146736	CA
3	204E00000X	Oral & Maxillofacial Surgery (D.M.D.)	000203543	CO

General Provider Information

NPI Number	:	1275831208
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KAMRAN DASTOURY M.D.

Provider Business Mailing Address
First Line	:	44015 7TH ST E
Second Line	:
City	:	LANCASTER
State	:	CA
Zip	:	93535-4124
Country	:	US
Telephone Number	:	661-466-8266
Fax Number	:

Provider Business Practice Location Address
First Line	:	2290 KIPLING ST UNIT 2
Second Line	:
City	:	LAKEWOOD
State	:	CO
Zip	:	80215-1546
Country	:	US
Telephone Number	:	661-466-8266
Fax Number	:

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

Provider Enumeration Date	:	02/28/2011
Last Update Date	:	05/05/2018

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