=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922133578
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DERHARTOUNIAN DENTAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/23/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6801 LANKERSHIM BLVD STE 101
-----------------------------------------------------
City | NORTH HOLLYWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91605-6112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-764-0718
-----------------------------------------------------
Fax | 818-503-9285
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6801 LANKERSHIM BLVD STE 101
-----------------------------------------------------
City | NORTH HOLLYWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91605-6112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-764-0718
-----------------------------------------------------
Fax | 818-503-9285
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT,CEO
-----------------------------------------------------
Name | HARMIK DERHARTOUNIAN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 818-764-0718
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 41394
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------