MEDICARE: CRYSTAL BRIGHT SMILE INC

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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1790371409
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CRYSTAL BRIGHT SMILE INC

Provider Business Mailing Address
First Line	:	7738 FOOTHILL BLVD
Second Line	:
City	:	TUJUNGA
State	:	CA
Zip	:	91042-2121
Country	:	US
Telephone Number	:	818-352-8200
Fax Number	:	818-293-3535

Provider Business Practice Location Address
First Line	:	7738 FOOTHILL BLVD
Second Line	:
City	:	TUJUNGA
State	:	CA
Zip	:	91042-2121
Country	:	US
Telephone Number	:	818-352-8200
Fax Number	:	818-293-3535

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. HENRY H DEMIRCHYAN
Credential	:
Telephone Number	:	818-352-8200

Provider Enumeration Date	:	12/16/2020
Last Update Date	:	12/16/2020

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