Provider Demographics
NPI:1477699635
Name:KHOSH, SHAYESTEH ROSTAMKOLAEI (DDS)
Entity Type:Individual
Prefix:
First Name:SHAYESTEH
Middle Name:ROSTAMKOLAEI
Last Name:KHOSH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:SAJAD
Other - Middle Name:
Other - Last Name:KHOSH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2114 N GLENOAKS BLVD
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91504-2827
Mailing Address - Country:US
Mailing Address - Phone:818-846-8915
Mailing Address - Fax:818-846-0958
Practice Address - Street 1:2114 N GLENOAKS BLVD
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91504-2827
Practice Address - Country:US
Practice Address - Phone:818-846-8915
Practice Address - Fax:818-846-0958
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42879122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG9402201OtherDENTICAL