Healthcare Provider Details

I. General information

NPI: 1124760160
Provider Name (Legal Business Name): BAROUIR DEIRMENJIAN DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2022
Last Update Date: 04/11/2022
Certification Date: 04/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23082 RIDGE ROUTE DR STE A
LAKE FOREST CA
92630-3691
US

IV. Provider business mailing address

12640 HESPERIA RD STE A
VICTORVILLE CA
92395-7753
US

V. Phone/Fax

Practice location:
  • Phone: 760-241-3336
  • Fax:
Mailing address:
  • Phone: 760-241-3336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: BAROUIR ARSHAG DEIRMENJIAN
Title or Position: OWNER/CEO
Credential:
Phone: 310-497-2211