=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114088580
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HIKANOUSH ANN GRACHIAN DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 323 N VEROUGO RD
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-637-2507
-----------------------------------------------------
Fax | 818-246-6436
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 424 OAK ST 233
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-545-0776
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 49103
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------