Healthcare Provider Details

I. General information

NPI: 1063669356
Provider Name (Legal Business Name): BAYRAKDARIAN ORTHODONTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2008
Last Update Date: 08/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

451 CLOVIS AVE SUITE 105
CLOVIS CA
93612-1194
US

IV. Provider business mailing address

451 CLOVIS AVE SUITE 105
CLOVIS CA
93612-1194
US

V. Phone/Fax

Practice location:
  • Phone: 559-298-4322
  • Fax:
Mailing address:
  • Phone: 559-298-4322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number50037
License Number StateCA

VIII. Authorized Official

Name: ISHKHAN BAYRAKDARIAN
Title or Position: SOLE MBR
Credential:
Phone: 818-522-2121