Healthcare Provider Details

I. General information

NPI: 1710164108
Provider Name (Legal Business Name): NATALYA SHAGRAMANOVA D.D.S. INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2008
Last Update Date: 01/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 N PACIFIC AVE
GLENDALE CA
91202-2359
US

IV. Provider business mailing address

7924 WOODMAN AVE #27
VAN NUYS CA
91402-6246
US

V. Phone/Fax

Practice location:
  • Phone: 818-240-0138
  • Fax:
Mailing address:
  • Phone: 818-653-7778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number54204
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number54204
License Number StateCA

VIII. Authorized Official

Name: DR. NATALYA SHAGRAMANOVA
Title or Position: OWNER/PRESIDENT
Credential: D.D.S.
Phone: 818-653-7778