Healthcare Provider Details

I. General information

NPI: 1497268700
Provider Name (Legal Business Name): DEIRMENJIAN DENTAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2017
Last Update Date: 08/31/2021
Certification Date: 08/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12640 HESPERIA RD STE C
VICTORVILLE CA
92395-7753
US

IV. Provider business mailing address

12640 HESPERIA RD STE C
VICTORVILLE CA
92395-7753
US

V. Phone/Fax

Practice location:
  • Phone: 760-241-3336
  • Fax: 760-243-7247
Mailing address:
  • Phone: 760-241-3336
  • Fax: 760-243-7247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number40804
License Number StateCA

VIII. Authorized Official

Name: BAROUIR DEIRMENJIAN
Title or Position: OWNER / PROVIDER
Credential: DDS
Phone: 760-241-3336