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General NPI Number Information
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NPI Number | 1629459573
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Entity Type | Individual
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Provider Name | SERGE BALTAYAN DDS, MD, MS
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Gender | Male
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Dates
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Enumeration Date | 06/17/2015
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Last Update Date | 06/30/2018
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Provider Practice Location Address
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Address Line | 10833 LE CONTE AVE
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City | LOS ANGELES
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State | CA
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Zip | 90095
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Country | US
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Telephone | 213-973-7437
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 5561
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City | GLENDALE
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State | CA
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Zip | 91221-5561
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 63026
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License Number State | CA
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