Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | 48132 | CA |
NPI | 1053614198 |
---|---|
Provider Name | Dr. Ameneh Khosrovani |
First Address | Berkeley, CA 94705-2091 |
Second Address | Berkeley, CA 94705-2091 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/12/2010 |
Last Update Date | 13/12/2010 |