=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790942472
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALEXANDRE HK TAVITIAN DDS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/20/2008
-----------------------------------------------------
Last Update Date | 05/20/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2625 W ALAMEDA AVE 420
-----------------------------------------------------
City | BURBANK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91505-4806
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-955-7788
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2448
-----------------------------------------------------
City | TOLUCA LAKE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91610-0448
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-955-7788
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ALEXANDRE HK TAVITIAN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 818-955-7788
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 40891
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------