=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851546493
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VAHAN GRIGORYAN, DDS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/24/2008
-----------------------------------------------------
Last Update Date | 12/12/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7993 SIERRA AVE SUITE D
-----------------------------------------------------
City | FONTANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92336-3330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-428-5111
-----------------------------------------------------
Fax | 909-428-5757
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7993 SIERRA AVE SUITE D
-----------------------------------------------------
City | FONTANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92336-3330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-428-5111
-----------------------------------------------------
Fax | 909-428-5757
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DENTIST
-----------------------------------------------------
Name | DR. VAHAN GRIGORYAN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 909-428-5111
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 49536
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------