MEDICARE: DR. IRINA VARDANYAN DMD

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	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1528991288
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. IRINA VARDANYAN DMD

Provider Business Mailing Address
First Line	:	400 S 40TH ST APT 122
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19104-6701
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	336 E HANES MILL RD
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27105-9135
Country	:	US
Telephone Number	:	336-450-2077
Fax Number	:

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

Provider Enumeration Date	:	06/04/2026
Last Update Date	:	06/04/2026

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