MEDICARE: SALLY KASHANI DDS, 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	302R00000X	Health Maintenance Organization	57454	CA

General Provider Information

NPI Number	:	1659764991
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SALLY KASHANI DDS, DENTAL CORPORATION

Provider Business Mailing Address
First Line	:	10719 RIVERSIDE DR
Second Line	:
City	:	TOLUCA LAKE
State	:	CA
Zip	:	91602-2312
Country	:	US
Telephone Number	:	818-508-7272
Fax Number	:	818-508-7444

Provider Business Practice Location Address
First Line	:	10719 RIVERSIDE DR
Second Line	:
City	:	TOLUCA LAKE
State	:	CA
Zip	:	91602-2312
Country	:	US
Telephone Number	:	818-508-7272
Fax Number	:	818-508-7444

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. SALLY KASHANI
Credential	:	DDS
Telephone Number	:	818-508-7272

Provider Enumeration Date	:	03/11/2015
Last Update Date	:	10/05/2015

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