Healthcare Provider Details

I. General information

NPI: 1649984865
Provider Name (Legal Business Name): SHANT TERTERYAN DDS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2023
Last Update Date: 01/31/2023
Certification Date: 01/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10436 SEPULVEDA BLVD
MISSION HILLS CA
91345-2424
US

IV. Provider business mailing address

3145 KINGRIDGE WAY
GLENDALE CA
91206-1028
US

V. Phone/Fax

Practice location:
  • Phone: 818-830-2828
  • Fax: 818-232-3083
Mailing address:
  • Phone: 818-665-5113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SHANT TERTERYAN
Title or Position: OWNER
Credential: DDS
Phone: 818-665-5113