Healthcare Provider Details

I. General information

NPI: 1003641978
Provider Name (Legal Business Name): ANDONIAN DENTAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2024
Last Update Date: 09/03/2024
Certification Date: 09/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18430 BROOKHURST ST STE 104
FOUNTAIN VALLEY CA
92708-6726
US

IV. Provider business mailing address

17312 DREY LN
HUNTINGTON BEACH CA
92647-5616
US

V. Phone/Fax

Practice location:
  • Phone: 714-963-3005
  • Fax:
Mailing address:
  • Phone: 614-256-6636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: DR. CHRISTOPHER WILLIAM ANDONIAN
Title or Position: PRESIDENT
Credential: DDS
Phone: 614-256-6636