Provider Demographics
NPI:1376695825
Name:IMANKHAN, HAMID REZA (DDS)
Entity Type:Individual
Prefix:DR
First Name:HAMID
Middle Name:REZA
Last Name:IMANKHAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2311 VENTURA BLVD
Mailing Address - Street 2:104
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91364
Mailing Address - Country:US
Mailing Address - Phone:818-225-7768
Mailing Address - Fax:818-225-1138
Practice Address - Street 1:13100 PONTOON PL
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-3634
Practice Address - Country:US
Practice Address - Phone:310-395-6084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA460731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice