=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508085622
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GOAR GRIGORIAN D.D.S.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/25/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3161 LOS FELIZ BLVD
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90039-1522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-663-2606
-----------------------------------------------------
Fax | 323-906-0072
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3161 LOS FELIZ BLVD
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90039-1522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-663-2606
-----------------------------------------------------
Fax | 323-906-0072
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 45868
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------