MEDICARE: SHAYESTEH ROSTAMKOLAEI KHOSH DDS

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	42879	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	G9402201	OTHER	CA	DENTICAL

General Provider Information

NPI Number	:	1477699635
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHAYESTEH ROSTAMKOLAEI KHOSH DDS

Provider Business Mailing Address
First Line	:	2114 N GLENOAKS BLVD
Second Line	:
City	:	BURBANK
State	:	CA
Zip	:	91504-2827
Country	:	US
Telephone Number	:	818-846-8915
Fax Number	:	818-846-0958

Provider Business Practice Location Address
First Line	:	2114 N GLENOAKS BLVD
Second Line	:
City	:	BURBANK
State	:	CA
Zip	:	91504-2827
Country	:	US
Telephone Number	:	818-846-8915
Fax Number	:	818-846-0958

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

Provider Enumeration Date	:	01/29/2007
Last Update Date	:	07/08/2007

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