Healthcare Provider Details

I. General information

NPI: 1407204522
Provider Name (Legal Business Name): OGANESYAN DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2016
Last Update Date: 06/29/2021
Certification Date: 06/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

313 E BROADWAY # 1625
GLENDALE CA
91205-1010
US

IV. Provider business mailing address

313 E BROADWAY # 1625
GLENDALE CA
91205-1010
US

V. Phone/Fax

Practice location:
  • Phone: 818-232-7227
  • Fax:
Mailing address:
  • Phone: 818-232-7227
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: TEVAN OGANESYAN
Title or Position: OWNER
Credential: DDS
Phone: 949-646-4300