=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033782180
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KAREN KEVIN KHACHATRYAN DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/16/2021
-----------------------------------------------------
Last Update Date | 03/24/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1877 E WASHINGTON BLVD
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91104-1648
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-601-8550
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11628 AMESTOY AVE
-----------------------------------------------------
City | GRANADA HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91344-2526
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-601-8550
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 106600
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 106600
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------