Healthcare Provider Details

I. General information

NPI: 1518210772
Provider Name (Legal Business Name): GREGORY OHANIAN D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2012
Last Update Date: 10/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 W COVINA BLVD STE 230
SAN DIMAS CA
91773-3205
US

IV. Provider business mailing address

165 S ROSEMEAD BLVD
PASADENA CA
91107-3955
US

V. Phone/Fax

Practice location:
  • Phone: 909-895-4914
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number59013
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: