MEDICARE: MGDVELADZE DDS INC.

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1205766342
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MGDVELADZE DDS INC.

Provider Business Mailing Address
First Line	:	5710 W 83RD ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90045-4301
Country	:	US
Telephone Number	:	424-216-0718
Fax Number	:

Provider Business Practice Location Address
First Line	:	5710 W 83RD ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90045-4301
Country	:	US
Telephone Number	:	424-216-0718
Fax Number	:

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	DR. EMILIIA MGDVELADZE
Credential	:	DDS
Telephone Number	:	424-216-0718

Provider Enumeration Date	:	05/20/2026
Last Update Date	:	05/20/2026

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