MEDICARE: DR. PEZHMAN MANSOURIAN 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	122300000X	Dentist	47522	CA

General Provider Information

NPI Number	:	1720003668
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PEZHMAN MANSOURIAN D.D.S.

Provider Business Mailing Address
First Line	:	4015 MISSION OAKS BLVD
Second Line	:	SUITE A
City	:	CAMARILLO
State	:	CA
Zip	:	93012-5156
Country	:	US
Telephone Number	:	805-987-2701
Fax Number	:	805-987-7092

Provider Business Practice Location Address
First Line	:	4015 MISSION OAKS BLVD
Second Line	:	SUITE A
City	:	CAMARILLO
State	:	CA
Zip	:	93012-5156
Country	:	US
Telephone Number	:	805-987-2701
Fax Number	:	805-987-7092

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

Provider Enumeration Date	:	07/13/2006
Last Update Date	:	08/15/2016

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