Healthcare Provider Details

I. General information

NPI: 1093359788
Provider Name (Legal Business Name): MARIANNE C DEMIRDJI DDS, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/05/2019
Last Update Date: 11/05/2021
Certification Date: 11/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 ARDEN AVE STE 200
GLENDALE CA
91203-1173
US

IV. Provider business mailing address

320 ARDEN AVE STE 200
GLENDALE CA
91203-1173
US

V. Phone/Fax

Practice location:
  • Phone: 818-242-3377
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number100674
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: