MEDICARE: I ZAK DDS PROF DENTAL CORP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	1223E0200X	Endodontics
2	1223G0001X	General Practice Dentistry
3	1223P0300X	Periodontics
4	1223S0112X	Oral and Maxillofacial Surgery (Dentist)
5	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry
6	122300000X	Dentist

General Provider Information

NPI Number	:	1316687114
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	I ZAK DDS PROF DENTAL CORP

Provider Business Mailing Address
First Line	:	10501 LAKEWOOD BLVD
Second Line	:
City	:	DOWNEY
State	:	CA
Zip	:	90241-2709
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5029 KANAN RD
Second Line	:
City	:	AGOURA HILLS
State	:	CA
Zip	:	91301-2515
Country	:	US
Telephone Number	:	818-991-9852
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	ILYA ZAK
Credential	:	DDS
Telephone Number	:	310-805-5201

Provider Enumeration Date	:	03/30/2022
Last Update Date	:	03/30/2022

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