Provider Demographics
NPI:1598835225
Name:SIMON MASOOD IMANUEL DMD,INC.
Entity Type:Organization
Organization Name:SIMON MASOOD IMANUEL DMD,INC.
Other - Org Name:KINGS FAMILY DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SIMON
Authorized Official - Middle Name:MASOOD
Authorized Official - Last Name:IMANUEL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:818-364-9444
Mailing Address - Street 1:14114 POLK ST
Mailing Address - Street 2:
Mailing Address - City:SYLMAR
Mailing Address - State:CA
Mailing Address - Zip Code:91342-2918
Mailing Address - Country:US
Mailing Address - Phone:818-364-9444
Mailing Address - Fax:818-367-6099
Practice Address - Street 1:14114 POLK ST
Practice Address - Street 2:
Practice Address - City:SYLMAR
Practice Address - State:CA
Practice Address - Zip Code:91342-2918
Practice Address - Country:US
Practice Address - Phone:818-364-9444
Practice Address - Fax:818-367-6099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2015-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39418122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG9291201Medicaid