Provider Demographics
NPI:1386053171
Name:TAJIK, KASRA (DDS)
Entity type:Individual
Prefix:
First Name:KASRA
Middle Name:
Last Name:TAJIK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10545 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91606-3916
Mailing Address - Country:US
Mailing Address - Phone:818-763-9353
Mailing Address - Fax:818-763-6227
Practice Address - Street 1:10545 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91606-3916
Practice Address - Country:US
Practice Address - Phone:818-763-9353
Practice Address - Fax:818-763-6227
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-06
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA636651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice