Healthcare Provider Details

I. General information

NPI: 1992179006
Provider Name (Legal Business Name): YEGHISHEH MIRZOYAN D.D.S., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2015
Last Update Date: 07/21/2022
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: 818-403-7655
  • Fax: 818-547-5510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number44534
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number63761
License Number StateCA

VIII. Authorized Official

Name: YEGHISHEH MIRZOYAN
Title or Position: DENTIST
Credential: D.D.S.
Phone: 818-419-0047