Healthcare Provider Details

I. General information

NPI: 1699831065
Provider Name (Legal Business Name): RUPEN DERBOGHOSIAN ITUTMAZIAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 02/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6812 WOODMAN AVE
VAN NUYS CA
91405-4208
US

IV. Provider business mailing address

75 PONCETTA DR APT 327
DALY CITY CA
94015-4810
US

V. Phone/Fax

Practice location:
  • Phone: 818-350-3451
  • Fax:
Mailing address:
  • Phone: 818-350-3451
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number5411
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberCDEN03106
License Number StateRI
# 3
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number03895
License Number StateNH
# 4
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number55226
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: