Provider Demographics
NPI:1578742953
Name:DERAGOBIAN, RITA T (DDS)
Entity Type:Individual
Prefix:DR
First Name:RITA
Middle Name:T
Last Name:DERAGOBIAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9509 CENTRAL AVE STE D
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:CA
Mailing Address - Zip Code:91763-2400
Mailing Address - Country:US
Mailing Address - Phone:909-399-3330
Mailing Address - Fax:
Practice Address - Street 1:9509 CENTRAL AVE. SUITE # D
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:CA
Practice Address - Zip Code:91763
Practice Address - Country:US
Practice Address - Phone:909-399-3330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-01
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55480122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist