Healthcare Provider Details

I. General information

NPI: 1093861882
Provider Name (Legal Business Name): GALLATIN DENTAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 06/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10805 PARAMOUNT BLVD SUITE B
DOWNEY CA
90241
US

IV. Provider business mailing address

10805 PARAMOUNT BLVD SUITE B
DOWNEY CA
90241
US

V. Phone/Fax

Practice location:
  • Phone: 562-869-1686
  • Fax: 562-861-1672
Mailing address:
  • Phone: 562-869-1686
  • Fax: 562-861-1672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number41887
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number47500
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number42015
License Number StateCA

VIII. Authorized Official

Name: DR. STEVE ARTHUR AIVAZIAN
Title or Position: SECRETARY
Credential: DMD
Phone: 562-869-1686