=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265630065
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EDWARD C TERZIAN D.M.D., M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/03/2007
-----------------------------------------------------
Last Update Date | 10/06/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5162 WHITTIER BLVD
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90022-3932
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-779-9418
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2029 VERDUGO BLVD # 151
-----------------------------------------------------
City | MONTROSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91020-1626
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-779-9418
-----------------------------------------------------
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 | OMS79
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------