MEDICARE: EBI NIKJOO DENTAL CORP

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

General Provider Information

NPI Number	:	1730649955
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EBI NIKJOO DENTAL CORP

Provider Business Mailing Address
First Line	:	5399 ORANGE AVE
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90805-6017
Country	:	US
Telephone Number	:	562-422-1000
Fax Number	:

Provider Business Practice Location Address
First Line	:	5399 ORANGE AVE
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90805-6017
Country	:	US
Telephone Number	:	562-422-1000
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	EBI DONAVAN NIKJOO
Credential	:	DDS
Telephone Number	:	562-422-1000

Provider Enumeration Date	:	03/22/2019
Last Update Date	:	03/22/2019

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