MEDICARE: CRYSTALLINE DENTAL STUDIO

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	:	1841798808
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CRYSTALLINE DENTAL STUDIO

Provider Business Mailing Address
First Line	:	6325 TOPANGA CANYON BLVD STE 233
Second Line	:
City	:	WOODLAND HILLS
State	:	CA
Zip	:	91367-2023
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6325 TOPANGA CANYON BLVD STE 233
Second Line	:
City	:	WOODLAND HILLS
State	:	CA
Zip	:	91367-2023
Country	:	US
Telephone Number	:	818-340-7108
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JEFF YANG
Credential	:
Telephone Number	:	213-999-0755

Provider Enumeration Date	:	01/24/2018
Last Update Date	:	01/24/2018

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Directions to “CRYSTALLINE DENTAL STUDIO ” Practice Location

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