Provider Demographics
NPI:1548454960
Name:S & S KHOSH DDS INC
Entity type:Organization
Organization Name:S & S KHOSH DDS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:SHAYESTEH
Authorized Official - Middle Name:ROSTAMKOLAIE
Authorized Official - Last Name:KHOSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-846-8915
Mailing Address - Street 1:2114 N GLENOAKS BLVD
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91504-2827
Mailing Address - Country:US
Mailing Address - Phone:818-846-8915
Mailing Address - Fax:818-846-0958
Practice Address - Street 1:2114 N GLENOAKS BLVD
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91504-2827
Practice Address - Country:US
Practice Address - Phone:818-846-8915
Practice Address - Fax:818-846-0958
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-29
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40633122300000X
CA42879122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG9402201Medicaid