MEDICARE: ALI KHOSROVANI 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	261QD0000X	Dental Clinic/Center	56085	CA

General Provider Information

NPI Number	:	1336383843
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALI KHOSROVANI DDS INC

Provider Business Mailing Address
First Line	:	4905 YORK BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90042-1609
Country	:	US
Telephone Number	:	323-255-8774
Fax Number	:	323-255-6259

Provider Business Practice Location Address
First Line	:	4905 YORK BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90042-1609
Country	:	US
Telephone Number	:	323-255-8774
Fax Number	:	323-255-6259

Authorized Official
Title or Position	:	OWNER DENTIST
Name	:	ALI M KHOSROVANI
Credential	:	DDS
Telephone Number	:	323-255-8774

Provider Enumeration Date	:	04/28/2009
Last Update Date	:	09/23/2020

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