MEDICARE: DR. RAFFI YESSAYANTZ D.D.S.

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	036039	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	B36039	OTHER	CA	DENTI-CAL

General Provider Information

NPI Number	:	1376676924
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RAFFI YESSAYANTZ D.D.S.

Provider Business Mailing Address
First Line	:	1155 N CENTRAL AVE STE 205
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91202-2540
Country	:	US
Telephone Number	:	818-243-5888
Fax Number	:	818-243-3465

Provider Business Practice Location Address
First Line	:	1155 N CENTRAL AVE STE 205
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91202-2540
Country	:	US
Telephone Number	:	818-243-5888
Fax Number	:	818-243-3465

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

Provider Enumeration Date	:	03/13/2007
Last Update Date	:	07/08/2007

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