Provider Demographics
NPI:1922505874
Name:TALESH, TINA
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:TALESH
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 1:4409 SAUGUS AVE APT 104
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-4066
Mailing Address - Country:US
Mailing Address - Phone:310-280-6087
Mailing Address - Fax:
Practice Address - Street 1:1609 WESTWOOD BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-5603
Practice Address - Country:US
Practice Address - Phone:310-998-7600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-08
Last Update Date:2023-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX34964122300000X, 1223G0001X
AZD010939122300000X
390200000X
CADDS1050621223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty