Provider Demographics
NPI:1396938569
Name:SIAMAK KHAKSHOOY D.D.S INC.
Entity type:Organization
Organization Name:SIAMAK KHAKSHOOY D.D.S INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:SIAMAK
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAKSHOOY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-925-9991
Mailing Address - Street 1:3451 W CENTURY BLVD STE B1
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90303-1228
Mailing Address - Country:US
Mailing Address - Phone:310-330-9000
Mailing Address - Fax:310-330-9303
Practice Address - Street 1:3451 W CENTURY BLVD STE B1
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90303-1228
Practice Address - Country:US
Practice Address - Phone:310-330-9000
Practice Address - Fax:310-330-9303
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SIAMAK KHAKSHOOY D.D.S INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-21
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54539122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1750437109OtherDENTICAL