MEDICARE: DR. LARA MESROB YEGHIASARIAN D.M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	9528	CO
2	1223E0200X	Endodontics	DS044849	PA

General Provider Information

NPI Number	:	1316130123
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LARA MESROB YEGHIASARIAN D.M.D.

Provider Business Mailing Address
First Line	:	7010 MORRISON AVE BLDG 128
Second Line	:	DENTAL ACTIVITY
City	:	FORT BENNING
State	:	GA
Zip	:	31905-0102
Country	:	US
Telephone Number	:	706-544-4530
Fax Number	:

Provider Business Practice Location Address
First Line	:	7010 MORRISON AVE BLDG 128
Second Line	:	DENTAL ACTIVITY
City	:	FORT BENNING
State	:	GA
Zip	:	31905-0102
Country	:	US
Telephone Number	:	706-544-4530
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/24/2007
Last Update Date	:	10/02/2024

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