Provider Demographics
NPI:1376942672
Name:ANKIN DERAGOBIAN D.D.S. INC.
Entity Type:Organization
Organization Name:ANKIN DERAGOBIAN D.D.S. INC.
Other - Org Name:GOLDEN SMILES DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANKIN
Authorized Official - Middle Name:
Authorized Official - Last Name:DERAGOBIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:909-481-8990
Mailing Address - Street 1:9635 MILLIKEN AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-9004
Mailing Address - Country:US
Mailing Address - Phone:909-481-8990
Mailing Address - Fax:909-481-8875
Practice Address - Street 1:9635 MILLIKEN AVE STE 103
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-9004
Practice Address - Country:US
Practice Address - Phone:909-481-8990
Practice Address - Fax:909-481-8875
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-22
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59757302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization