Provider Demographics
NPI:1710332838
Name:TAJIK NAMINIK & KOSHKI DDS INC
Entity Type:Organization
Organization Name:TAJIK NAMINIK & KOSHKI DDS INC
Other - Org Name:MODERN SMILES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KASRA
Authorized Official - Middle Name:
Authorized Official - Last Name:TAJIK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:818-763-9395
Mailing Address - Street 1:10545 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91606-3916
Mailing Address - Country:US
Mailing Address - Phone:818-763-9353
Mailing Address - Fax:818-763-6227
Practice Address - Street 1:10545 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91606-3916
Practice Address - Country:US
Practice Address - Phone:818-763-9353
Practice Address - Fax:818-763-6227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-26
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA636651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA63665OtherLICENCE
CA61426OtherLICENCE
CA44505OtherLICENCE