Healthcare Provider Details

I. General information

NPI: 1780848887
Provider Name (Legal Business Name): EDVIN AGADZHANOV D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2008
Last Update Date: 07/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

923 N MILPAS ST
SANTA BARBARA CA
93103-2331
US

IV. Provider business mailing address

19231 SHERMAN WAY #23
RESEDA CA
91335
US

V. Phone/Fax

Practice location:
  • Phone: 805-884-1998
  • Fax:
Mailing address:
  • Phone: 818-344-1723
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number57233
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: