MEDICARE: GANKIN MIKHAIL DMD, A DENTAL CORP

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	261QD0000X	Dental Clinic/Center	53214	CA

General Provider Information

NPI Number	:	1326209008
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GANKIN MIKHAIL DMD, A DENTAL CORP

Provider Business Mailing Address
First Line	:	PO BOX 461459
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90046-9459
Country	:	US
Telephone Number	:	323-868-6670
Fax Number	:

Provider Business Practice Location Address
First Line	:	7901 SANTA MONICA BLVD # 111
Second Line	:
City	:	WEST HOLLYWOOD
State	:	CA
Zip	:	90046-5177
Country	:	US
Telephone Number	:	323-822-1222
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MIKHAIL GANKIN
Credential	:	DMD
Telephone Number	:	323-868-6670

Provider Enumeration Date	:	06/24/2008
Last Update Date	:	01/26/2012

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