Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 48376 | CA |
Y | 1223P0300X | Periodontist | 48376 | CA |
NPI | 1124241575 |
---|---|
Provider Name | Al Shyste Manesh |
First Address | Mission Viejo, CA 92691 |
Second Address | Laguna Hills, CA 92653-4344 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/04/2007 |
Last Update Date | 20/11/2020 |