Healthcare Provider Details

I. General information

NPI: 1972869337
Provider Name (Legal Business Name): VATCHE WASSILIAN DDS APDC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2012
Last Update Date: 04/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1504 SHAW AVE
CLOVIS CA
93611-4028
US

IV. Provider business mailing address

1504 SHAW AVE
CLOVIS CA
93611-4028
US

V. Phone/Fax

Practice location:
  • Phone: 559-323-7777
  • Fax: 559-323-7776
Mailing address:
  • Phone: 559-323-7777
  • Fax: 559-323-7776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number58255
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number58255
License Number StateCA

VIII. Authorized Official

Name: VATCHE SARKIS WASSILIAN
Title or Position: OWNER
Credential: DDS
Phone: 559-323-7777