MEDICARE: MARIAM NOEMI KHACHATRIAN DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	109116	CA

General Provider Information

NPI Number	:	1093598500
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIAM NOEMI KHACHATRIAN DDS

Provider Business Mailing Address
First Line	:	515 W BROADWAY APT 214
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91204-1082
Country	:	US
Telephone Number	:	818-482-4159
Fax Number	:

Provider Business Practice Location Address
First Line	:	515 W BROADWAY APT 214
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91204-1082
Country	:	US
Telephone Number	:	818-482-4159
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/17/2023
Last Update Date	:	12/27/2023

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