Provider Demographics
NPI:1376825794
Name:EMMANUEL KANDKHOROV, D.D.S., INC.
Entity Type:Organization
Organization Name:EMMANUEL KANDKHOROV, D.D.S., INC.
Other - Org Name:MMSI DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EMMANUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KANDKHOROV
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:949-825-7799
Mailing Address - Street 1:33 CREEK RD STE A-150
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92604-4791
Mailing Address - Country:US
Mailing Address - Phone:949-825-7799
Mailing Address - Fax:
Practice Address - Street 1:33 CREEK RD STE A-150
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-4791
Practice Address - Country:US
Practice Address - Phone:949-825-7799
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-12
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50617122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty