MEDICARE: KAZARIAN, KHACHATRYAN, AZATYAN, A PROFESSIONAL DENTAL CORPORATION

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	:	1811627763
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KAZARIAN, KHACHATRYAN, AZATYAN, A PROFESSIONAL DENTAL CORPORATION

Provider Business Mailing Address
First Line	:	1698 CRUICKSHANK DR STE B
Second Line	:
City	:	EL CENTRO
State	:	CA
Zip	:	92243-1462
Country	:	US
Telephone Number	:	818-300-5849
Fax Number	:

Provider Business Practice Location Address
First Line	:	508 W ATEN RD
Second Line	:
City	:	IMPERIAL
State	:	CA
Zip	:	92251-9718
Country	:	US
Telephone Number	:	760-355-4444
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	HAMLET KHACHATRYAN
Credential	:	DDS
Telephone Number	:	818-300-5849

Provider Enumeration Date	:	06/14/2022
Last Update Date	:	06/14/2022

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