Healthcare Provider Details

I. General information

NPI: 1477471563
Provider Name (Legal Business Name): DAVIT POGHOSYAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2026
Last Update Date: 07/07/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

755 W RANCHO VISTA BLVD
PALMDALE CA
93551-3735
US

IV. Provider business mailing address

7804 FERNCOLA AVE
SUN VALLEY CA
91352
US

V. Phone/Fax

Practice location:
  • Phone: 661-265-7800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number112992
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: