Provider Demographics
NPI:1548009905
Name:KHOSHKHELGHAT, TALIEH (RDH)
Entity type:Individual
Prefix:MRS
First Name:TALIEH
Middle Name:
Last Name:KHOSHKHELGHAT
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:617 ORANGE GROVE AVE UNIT G
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-2355
Mailing Address - Country:US
Mailing Address - Phone:310-880-5417
Mailing Address - Fax:
Practice Address - Street 1:1960 GLENOAKS BLVD STE 2
Practice Address - Street 2:
Practice Address - City:SAN FERNANDO
Practice Address - State:CA
Practice Address - Zip Code:91340-1691
Practice Address - Country:US
Practice Address - Phone:818-361-1717
Practice Address - Fax:818-361-1016
Is Sole Proprietor?:No
Enumeration Date:2024-05-23
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDH35412124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist