Healthcare Provider Details

I. General information

NPI: 1659938470
Provider Name (Legal Business Name): K. SHAGRAMANOVA DENTAL CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2019
Last Update Date: 05/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3175 FIRESTONE BLVD # 201
SOUTH GATE CA
90280-2951
US

IV. Provider business mailing address

410 W COLORADO ST
GLENDALE CA
91204-1504
US

V. Phone/Fax

Practice location:
  • Phone: 323-749-0137
  • Fax: 323-749-0334
Mailing address:
  • Phone: 818-956-9907
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State

VIII. Authorized Official

Name: DR. KRISTINA SHAGRAMANOVA
Title or Position: CEO
Credential: DDS
Phone: 818-636-9208