Provider Demographics
NPI:1568722437
Name:SAGARIAN,A PROFESSIONAL DENTAL CORPORATION
Entity Type:Organization
Organization Name:SAGARIAN,A PROFESSIONAL DENTAL CORPORATION
Other - Org Name:ROSETOWN FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:MAIS
Authorized Official - Last Name:SAGARIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:661-758-5338
Mailing Address - Street 1:1229 7TH ST
Mailing Address - Street 2:
Mailing Address - City:WASCO
Mailing Address - State:CA
Mailing Address - Zip Code:93280-1820
Mailing Address - Country:US
Mailing Address - Phone:661-758-5338
Mailing Address - Fax:661-758-8150
Practice Address - Street 1:1229 7TH ST
Practice Address - Street 2:
Practice Address - City:WASCO
Practice Address - State:CA
Practice Address - Zip Code:93280-1820
Practice Address - Country:US
Practice Address - Phone:661-758-5338
Practice Address - Fax:661-758-8150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-24
Last Update Date:2012-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA436551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG91682Medicaid