Provider Demographics
NPI:1558053025
Name:15719 VANOWEN ST DENTAL GROUP OF YEGHISHEH MIRZOYAN DDS INC
Entity Type:Organization
Organization Name:15719 VANOWEN ST DENTAL GROUP OF YEGHISHEH MIRZOYAN DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:YEGHISHEH
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRZOYAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:818-927-3113
Mailing Address - Street 1:6440 GREENBUSH AVE
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91401-1839
Mailing Address - Country:US
Mailing Address - Phone:818-419-0047
Mailing Address - Fax:
Practice Address - Street 1:15719 VANOWEN ST
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91406-5030
Practice Address - Country:US
Practice Address - Phone:818-419-0047
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-23
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery