Provider Demographics
NPI:1295227288
Name:RITA T. DERAGOBIAN DDS, INC.
Entity Type:Organization
Organization Name:RITA T. DERAGOBIAN DDS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RITA
Authorized Official - Middle Name:
Authorized Official - Last Name:DERAGOBIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:626-914-3900
Mailing Address - Street 1:1435 E ROUTE 66 STE D
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91740-3748
Mailing Address - Country:US
Mailing Address - Phone:626-914-3900
Mailing Address - Fax:626-914-0019
Practice Address - Street 1:1435 E ROUTE 66 STE D
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91740-3748
Practice Address - Country:US
Practice Address - Phone:626-914-3900
Practice Address - Fax:626-914-0019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-05
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223S0112X
CA55480261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Multi-Specialty