Healthcare Provider Details

I. General information

NPI: 1891719217
Provider Name (Legal Business Name): ISHKHAN JOHN BAYRAKDARIAN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 10/12/2020
Certification Date: 10/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1616 W SHAW AVE STE A6
FRESNO CA
93711
US

IV. Provider business mailing address

1616 W SHAW AVE STE A6
FRESNO CA
93711-3513
US

V. Phone/Fax

Practice location:
  • Phone: 559-222-2522
  • Fax: 559-222-3022
Mailing address:
  • Phone: 559-222-2522
  • Fax: 559-222-3022

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:
Title or Position:
Credential:
Phone: