Healthcare Provider Details

I. General information

NPI: 1467740852
Provider Name (Legal Business Name): VAHE OHANESSIAN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2011
Last Update Date: 02/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1016 E BROADWAY 104
GLENDALE CA
91205-4532
US

IV. Provider business mailing address

1016 E BROADWAY 104
GLENDALE CA
91205-4532
US

V. Phone/Fax

Practice location:
  • Phone: 818-259-1000
  • Fax:
Mailing address:
  • Phone: 818-259-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number36995
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: