Healthcare Provider Details

I. General information

NPI: 1558053025
Provider Name (Legal Business Name): 15719 VANOWEN ST DENTAL GROUP OF YEGHISHEH MIRZOYAN DDS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2023
Last Update Date: 05/23/2023
Certification Date: 05/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15719 VANOWEN ST
VAN NUYS CA
91406-5030
US

IV. Provider business mailing address

6440 GREENBUSH AVE
VAN NUYS CA
91401-1839
US

V. Phone/Fax

Practice location:
  • Phone: 818-419-0047
  • Fax:
Mailing address:
  • Phone: 818-419-0047
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: YEGHISHEH MIRZOYAN
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 818-927-3113