MEDICARE: BARKHORDAR DENTAL 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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1538607965	OTHER	CA	NPI
2	1821229444	OTHER	CA	NPI

General Provider Information

NPI Number	:	1396260972
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BARKHORDAR DENTAL INC

Provider Business Mailing Address
First Line	:	310 E GRAND AVE STE 102
Second Line	:
City	:	EL SEGUNDO
State	:	CA
Zip	:	90245-3871
Country	:	US
Telephone Number	:	424-277-1138
Fax Number	:

Provider Business Practice Location Address
First Line	:	310 E GRAND AVE STE 102
Second Line	:
City	:	EL SEGUNDO
State	:	CA
Zip	:	90245-3871
Country	:	US
Telephone Number	:	424-277-1138
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	OMID R BARKHORDAR
Credential	:	DDS
Telephone Number	:	424-277-1138

Provider Enumeration Date	:	08/04/2017
Last Update Date	:	07/21/2022

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