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General NPI Number Information
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NPI Number | 1376942672
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Entity Type | Organization
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Legal Business Name | ANKIN DERAGOBIAN D.D.S. INC.
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Dates
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Enumeration Date | 08/22/2014
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Last Update Date | 01/28/2015
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Provider Practice Location Address
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Address Line | 9635 MILLIKEN AVE STE 103
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City | RANCHO CUCAMONGA
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State | CA
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Zip | 91730-9004
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Country | US
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Telephone | 909-481-8990
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Fax | 909-481-8875
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Provider Business Mailing Address
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Address Line | 9635 MILLIKEN AVE STE 103
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City | RANCHO CUCAMONGA
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State | CA
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Zip | 91730-9004
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Country | US
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Telephone | 909-481-8990
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Fax | 909-481-8875
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Authorized Official
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Title or Position | OWNER/PRESIDENT
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Name | DR. ANKIN DERAGOBIAN
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Credential | DDS
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Telephone | 909-481-8990
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302F00000X
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Taxonomy Name | Exclusive Provider Organization
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License Number | 59757
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License Number State | CA
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