Provider Demographics
NPI:1508069576
Name:KELISHADI SAMANI DENTAL CORP
Entity Type:Organization
Organization Name:KELISHADI SAMANI DENTAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:MARJAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KELISHADI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-830-3500
Mailing Address - Street 1:23541 AVALON BLVD
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90745
Mailing Address - Country:US
Mailing Address - Phone:310-830-3500
Mailing Address - Fax:310-830-7994
Practice Address - Street 1:23541 AVALON BLVD
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90745
Practice Address - Country:US
Practice Address - Phone:310-830-3500
Practice Address - Fax:310-830-7994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-07
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41930122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG9300701Medicaid
CA809101OtherUNITED CONCORDIA
CA612331200OtherAFFILIATED COMPUTER SERVI
CAG9805001OtherHEALTHY FAMILIES