Healthcare Provider Details

I. General information

NPI: 1649781758
Provider Name (Legal Business Name): GAYANE MATULIANDDS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 GRIFFITH PARK BLVD
LOS ANGELES CA
90039-2520
US

IV. Provider business mailing address

2650 GRIFFITH PARK BLVD
LOS ANGELES CA
90039-2520
US

V. Phone/Fax

Practice location:
  • Phone: 323-660-5522
  • Fax: 818-551-9976
Mailing address:
  • Phone: 323-660-5522
  • Fax: 818-551-9976

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number44214
License Number StateDE

VIII. Authorized Official

Name: DR. GAYANE A MATULIAN
Title or Position: DENTIST
Credential: DDS
Phone: 323-660-5522