Healthcare Provider Details

I. General information

NPI: 1063799823
Provider Name (Legal Business Name): JACKLYN MARTIROSYAN RDHAP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ZHAKLIN MARTIROSYAN

II. Dates (important events)

Enumeration Date: 11/08/2011
Last Update Date: 11/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3727 W. MAGNOLIA BLVD. #436
BURBANK CA
91505
US

IV. Provider business mailing address

3727 W. MAGNOLIA BLVD. #436
BURBANK CA
91505
US

V. Phone/Fax

Practice location:
  • Phone: 818-429-9454
  • Fax:
Mailing address:
  • Phone: 818-429-9454
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number380
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: