=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790439024
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AVANESS DENTAL GROUP INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2022
-----------------------------------------------------
Last Update Date | 02/06/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25880 TOURNAMENT RD STE 212
-----------------------------------------------------
City | VALENCIA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91355-2389
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-254-5588
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25880 TOURNAMENT RD STE 212
-----------------------------------------------------
City | VALENCIA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91355-2389
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-209-7702
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRESIDENT/DENTIST
-----------------------------------------------------
Name | DR. KARINEH AVANESS
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 818-209-7702
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------