Provider Demographics
NPI:1558852863
Name:I J BAYRAKDARIAN DMD A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:I J BAYRAKDARIAN DMD A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BURUCA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:559-377-4000
Mailing Address - Street 1:1616 W SHAW AVE STE A6
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-3513
Mailing Address - Country:US
Mailing Address - Phone:559-377-4000
Mailing Address - Fax:559-479-4736
Practice Address - Street 1:1450 E PROSPERITY AVE STE 101
Practice Address - Street 2:
Practice Address - City:TULARE
Practice Address - State:CA
Practice Address - Zip Code:93274-8054
Practice Address - Country:US
Practice Address - Phone:559-377-4000
Practice Address - Fax:559-479-4736
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-22
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA500371223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA203643578Medicaid