Provider Demographics
NPI:1538288667
Name:GHAZAR M. GHAZARYAN D.D.S.,INC
Entity Type:Organization
Organization Name:GHAZAR M. GHAZARYAN D.D.S.,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GHAZAR
Authorized Official - Middle Name:MIKHAIL
Authorized Official - Last Name:GHAZARYAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:818-780-8400
Mailing Address - Street 1:13746 VICTORY BLVD STE 113
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91401-6717
Mailing Address - Country:US
Mailing Address - Phone:818-780-8400
Mailing Address - Fax:818-780-2275
Practice Address - Street 1:13746 VICTORY BLVD STE 113
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91401-6717
Practice Address - Country:US
Practice Address - Phone:818-780-8400
Practice Address - Fax:818-780-2275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA493221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG93223-01Medicaid