Provider Demographics
NPI:1437759164
Name:TERTERYAN, SHANT (DDS)
Entity Type:Individual
Prefix:
First Name:SHANT
Middle Name:
Last Name:TERTERYAN
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 1:10436 SEPULVEDA BLVD
Mailing Address - Street 2:
Mailing Address - City:MISSION HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91345-2424
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10436 SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:MISSION HILLS
Practice Address - State:CA
Practice Address - Zip Code:91345-2424
Practice Address - Country:US
Practice Address - Phone:818-830-2828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-30
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1056671223G0001X
CADDS105667122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice