Healthcare Provider Details

I. General information

NPI: 1457712408
Provider Name (Legal Business Name): LIANA DAGDAVARYAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2016
Last Update Date: 12/11/2023
Certification Date: 12/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 COLCHESTER AVE
BURLINGTON VT
05401-1473
US

IV. Provider business mailing address

200 MULLINS DR
LEBANON OR
97355-3983
US

V. Phone/Fax

Practice location:
  • Phone: 802-847-2415
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number12822273-1204
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number032-0134152
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: