Healthcare Provider Details

I. General information

NPI: 1295227288
Provider Name (Legal Business Name): RITA T. DERAGOBIAN DDS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2018
Last Update Date: 01/08/2020
Certification Date: 01/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1435 E ROUTE 66 STE D
GLENDORA CA
91740-3748
US

IV. Provider business mailing address

1435 E ROUTE 66 STE D
GLENDORA CA
91740-3748
US

V. Phone/Fax

Practice location:
  • Phone: 626-914-3900
  • Fax: 626-914-0019
Mailing address:
  • Phone: 626-914-3900
  • Fax: 626-914-0019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number55480
License Number StateCA

VIII. Authorized Official

Name: DR. RITA DERAGOBIAN
Title or Position: DENTIST/OWNER
Credential: DDS
Phone: 626-914-3900