Healthcare Provider Details

I. General information

NPI: 1528544814
Provider Name (Legal Business Name): B. DEIRMENJIAN, DDS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2018
Last Update Date: 08/31/2021
Certification Date: 08/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1440 W MANCHESTER AVE
LOS ANGELES CA
90047-5422
US

IV. Provider business mailing address

12640 HESPERIA RD STE A
VICTORVILLE CA
92395-7753
US

V. Phone/Fax

Practice location:
  • Phone: 323-753-1141
  • Fax:
Mailing address:
  • Phone: 760-241-3336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number40804
License Number StateCA

VIII. Authorized Official

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