Provider Demographics
NPI:1508281387
Name:ANDRE ELIASIAN DENTAL CORPORATION
Entity Type:Organization
Organization Name:ANDRE ELIASIAN DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDRE
Authorized Official - Middle Name:
Authorized Official - Last Name:ELIASIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:818-632-5005
Mailing Address - Street 1:290 E VERDUGO AVE
Mailing Address - Street 2:208
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91502-1300
Mailing Address - Country:US
Mailing Address - Phone:818-861-7427
Mailing Address - Fax:818-861-7426
Practice Address - Street 1:1224 STANLEY AVE UNIT 10
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-5629
Practice Address - Country:US
Practice Address - Phone:818-632-5005
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-03
Last Update Date:2014-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA62927122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty