=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629282611
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EDWIN BABADJANIAN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2007
-----------------------------------------------------
Last Update Date | 07/26/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1101 N PACIFIC AVE STE 206
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91202-4367
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-548-5544
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1101 N PACIFIC AVE STE 206
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91202-4367
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-548-5544
-----------------------------------------------------
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 | DDS59108
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 052912
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1223E0200X
-----------------------------------------------------
Taxonomy Name | Endodontics
-----------------------------------------------------
License Number | DDS59108
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------