Provider Demographics
NPI:1073887790
Name:MAHTESYAN, SERGEY (DDS)
Entity Type:Individual
Prefix:
First Name:SERGEY
Middle Name:
Last Name:MAHTESYAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:372 E OLIVE AVE
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91502-1215
Mailing Address - Country:US
Mailing Address - Phone:818-450-5000
Mailing Address - Fax:818-736-5003
Practice Address - Street 1:372 E OLIVE AVE
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91502-1215
Practice Address - Country:US
Practice Address - Phone:818-450-5000
Practice Address - Fax:818-736-5003
Is Sole Proprietor?:No
Enumeration Date:2012-02-27
Last Update Date:2020-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA612031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice