MEDICARE: DR. HAMID REZA IMANKHAN D.D.S.

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	1223G0001X	General Practice Dentistry	46073	CA

General Provider Information

NPI Number	:	1376695825
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HAMID REZA IMANKHAN D.D.S.

Provider Business Mailing Address
First Line	:	2311 VENTURA BLVD
Second Line	:	104
City	:	WOODLAND HILLS
State	:	CA
Zip	:	91364
Country	:	US
Telephone Number	:	818-225-7768
Fax Number	:	818-225-1138

Provider Business Practice Location Address
First Line	:	13100 PONTOON PL
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90049-3634
Country	:	US
Telephone Number	:	310-395-6084
Fax Number	:

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

Provider Enumeration Date	:	01/17/2007
Last Update Date	:	07/08/2007

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