Healthcare Provider Details

I. General information

NPI: 1972871309
Provider Name (Legal Business Name): B. DEIRMENJIAN, DDS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2011
Last Update Date: 12/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12820 VICTORY BLVD
NORTH HOLLYWOOD CA
91606-3013
US

IV. Provider business mailing address

260 S GLENDORA AVE STE 200
WEST COVINA CA
91790-3041
US

V. Phone/Fax

Practice location:
  • Phone: 818-792-4500
  • Fax: 818-792-4501
Mailing address:
  • Phone: 626-214-1900
  • Fax: 626-214-1954

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number40804
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number40804
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number40804
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number40804
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number40804
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number40804
License Number StateCA
# 7
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number40804
License Number StateCA

VIII. Authorized Official

Name: DR. BAROUIR DEIRMENJIAN
Title or Position: CEO/PRESIDENT
Credential: DDS
Phone: 310-923-6981