Provider Demographics
NPI:1720562978
Name:KHONSARI, MELODY
Entity Type:Individual
Prefix:
First Name:MELODY
Middle Name:
Last Name:KHONSARI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20410 RUNNYMEDE ST
Mailing Address - Street 2:
Mailing Address - City:WINNETKA
Mailing Address - State:CA
Mailing Address - Zip Code:91306-2844
Mailing Address - Country:US
Mailing Address - Phone:818-668-7546
Mailing Address - Fax:
Practice Address - Street 1:1760 E AVENIDA DE LOS ARBOLES STE A
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91362-1392
Practice Address - Country:US
Practice Address - Phone:805-494-5255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-23
Last Update Date:2018-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1031071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice