=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093861882
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GALLATIN DENTAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2007
-----------------------------------------------------
Last Update Date | 06/01/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10805 PARAMOUNT BLVD SUITE B
-----------------------------------------------------
City | DOWNEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90241
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-869-1686
-----------------------------------------------------
Fax | 562-861-1672
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10805 PARAMOUNT BLVD SUITE B
-----------------------------------------------------
City | DOWNEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90241
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-869-1686
-----------------------------------------------------
Fax | 562-861-1672
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SECRETARY
-----------------------------------------------------
Name | DR. STEVE ARTHUR AIVAZIAN
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 562-869-1686
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 42015
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 47500
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 41887
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------