MEDICARE: BABAK KHAYATAN 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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1639648413
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BABAK KHAYATAN DDS INC.

Provider Business Mailing Address
First Line	:	2734 DELTA FAIR BLVD
Second Line	:
City	:	ANTIOCH
State	:	CA
Zip	:	94509-4100
Country	:	US
Telephone Number	:	925-778-1234
Fax Number	:

Provider Business Practice Location Address
First Line	:	2734 DELTA FAIR BLVD
Second Line	:
City	:	ANTIOCH
State	:	CA
Zip	:	94509-4100
Country	:	US
Telephone Number	:	925-778-1234
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. BABAK KHAYATAN
Credential	:	DDS
Telephone Number	:	925-778-1234

Provider Enumeration Date	:	11/21/2018
Last Update Date	:	11/21/2018

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