Provider Demographics
NPI:1043340227
Name:KATSURA KHALIL NAKAZATO KHOSROVANI DDS INC.
Entity Type:Organization
Organization Name:KATSURA KHALIL NAKAZATO KHOSROVANI DDS INC.
Other - Org Name:PEDIATRIC DENTISTRY
Other - Org Type:Other Name
Authorized Official - Title/Position:DENTAL PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MAHI
Authorized Official - Middle Name:
Authorized Official - Last Name:AMERINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-848-6494
Mailing Address - Street 1:2640 TELEGRAPH AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94704-3374
Mailing Address - Country:US
Mailing Address - Phone:510-848-6494
Mailing Address - Fax:510-981-1159
Practice Address - Street 1:2640 TELEGRAPH AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94704-3374
Practice Address - Country:US
Practice Address - Phone:510-848-6494
Practice Address - Fax:510-981-1159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA327281223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty