Healthcare Provider Details

I. General information

NPI: 1104254374
Provider Name (Legal Business Name): V A HALAJIAN DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2013
Last Update Date: 10/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 N MARYLAND AVE SUITE 206
GLENDALE CA
91206-4261
US

IV. Provider business mailing address

230 N MARYLAND AVE SUITE 206
GLENDALE CA
91206-4261
US

V. Phone/Fax

Practice location:
  • Phone: 818-547-2804
  • Fax: 818-502-1197
Mailing address:
  • Phone: 818-547-2804
  • Fax: 818-502-1197

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number56717
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number58380
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number30624
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number55829
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number57793
License Number StateCA

VIII. Authorized Official

Name: DR. VIC HALAJIAN
Title or Position: PRESIDENT
Credential:
Phone: 818-416-4776