MEDICARE: DAVID RABIZADEH, DDS, A PROFESSIONAL DENTAL CORPORATION

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
2	122300000X	Dentist	41984	CA
3	122300000X	Dentist		CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	G9345701	OTHER	CA	MEDICAL

General Provider Information

NPI Number	:	1346303112
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DAVID RABIZADEH, DDS, A PROFESSIONAL DENTAL CORPORATION

Provider Business Mailing Address
First Line	:	1018 1/2 N. VERMONT AVE.
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90029-3519
Country	:	US
Telephone Number	:	323-953-7700
Fax Number	:	323-953-7704

Provider Business Practice Location Address
First Line	:	1018 1/2 N. VERMONT AVE.
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90029-3519
Country	:	US
Telephone Number	:	323-953-7700
Fax Number	:	323-953-7704

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DAVID SHAHRAM RABIZADEH
Credential	:	DDS
Telephone Number	:	323-526-1992

Provider Enumeration Date	:	12/19/2006
Last Update Date	:	02/12/2020

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