Healthcare Provider Details

I. General information

NPI: 1285986505
Provider Name (Legal Business Name): JACK CHARLES OHANESIAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

1879 E FIR AVE STE 101
FRESNO CA
93720-3861
US

IV. Provider business mailing address

1221 S CLOVIS AVE
FRESNO CA
93727-5316
US

V. Phone/Fax

Practice location:
  • Phone: 559-322-6060
  • Fax: 559-322-7888
Mailing address:
  • Phone: 559-213-0932
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number61812
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: