Healthcare Provider Details

I. General information

NPI: 1477896868
Provider Name (Legal Business Name): TATIANA VAZIRA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2013
Last Update Date: 04/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1624 W OLIVE SUITE H
BURBANK CA
91506
US

IV. Provider business mailing address

1624 W OLIVE SUITE H
BURBANK CA
91506
US

V. Phone/Fax

Practice location:
  • Phone: 818-842-4746
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number43090
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: