Healthcare Provider Details

I. General information

NPI: 1497156038
Provider Name (Legal Business Name): YEGHISHEH MIRZOYAN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2014
Last Update Date: 08/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14435 SHERMAN WAY STE 110
VAN NUYS CA
91405-6229
US

IV. Provider business mailing address

6440 GREENBUSH AVE
VAN NUYS CA
91401-1839
US

V. Phone/Fax

Practice location:
  • Phone: 818-927-3113
  • Fax: 818-547-5510
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number44534
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number63761
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: