MEDICARE: GHAZARYAN PROFESSIONAL DENTAL CORP.

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	1223G0001X	General Practice Dentistry	53702	CA

General Provider Information

NPI Number	:	1245620095
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GHAZARYAN PROFESSIONAL DENTAL CORP.

Provider Business Mailing Address
First Line	:	10445 LAUREL CANYON BLVD.
Second Line	:
City	:	PACOIMA
State	:	CA
Zip	:	91331-3605
Country	:	US
Telephone Number	:	818-890-8070
Fax Number	:	818-890-1474

Provider Business Practice Location Address
First Line	:	8361 LAUREL CANYON BLVD
Second Line	:
City	:	SUN VALLEY
State	:	CA
Zip	:	91352-3809
Country	:	US
Telephone Number	:	818-890-8070
Fax Number	:	818-890-1474

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. NJDEH NICK GHAZARYAN
Credential	:	DDS
Telephone Number	:	818-970-5070

Provider Enumeration Date	:	02/02/2015
Last Update Date	:	02/02/2015

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