Provider Demographics
NPI:1003953126
Name:KHOSHROZEH DENTAL CORPORATION
Entity Type:Organization
Organization Name:KHOSHROZEH DENTAL CORPORATION
Other - Org Name:CALIFORNIA FAMILY DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MEHRDAD
Authorized Official - Middle Name:
Authorized Official - Last Name:KHOSHROZEH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-386-8246
Mailing Address - Street 1:4080 WHITTIER BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90023-2527
Mailing Address - Country:US
Mailing Address - Phone:323-582-4474
Mailing Address - Fax:323-582-3101
Practice Address - Street 1:4080 WHITTIER BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90023-2527
Practice Address - Country:US
Practice Address - Phone:323-582-4744
Practice Address - Fax:323-582-3101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA499061223E0200X
CA439901223G0001X
CA435151223G0001X
CA499091223G0001X
CA530641223P0221X
CA539011223P0221X
CA306241223P0300X
CA734791223S0112X
CAA912741223S0112X
CA204821223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG91571-01OtherDENTICAL OFFICE NUMBER
CA=========OtherOFFICE TAX ID NUMBER