Provider Demographics
NPI:1508076688
Name:MANOUKIAN, ALICE CHALIAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:ALICE
Middle Name:CHALIAN
Last Name:MANOUKIAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:ALICE
Other - Middle Name:M
Other - Last Name:CHALIAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:1512 W BURBANK BLVD
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91506-1309
Mailing Address - Country:US
Mailing Address - Phone:818-761-5863
Mailing Address - Fax:818-843-1663
Practice Address - Street 1:1512 W BURBANK BLVD
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91506-1309
Practice Address - Country:US
Practice Address - Phone:818-761-5863
Practice Address - Fax:818-843-1663
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA335581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG90617-01Medicaid
CA33558OtherCA DENTAL LICENSE NUMBER