Provider Demographics
NPI:1629282611
Name:BABADJANIAN, EDWIN
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:
Last Name:BABADJANIAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 N PACIFIC AVE STE 206
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91202-4367
Mailing Address - Country:US
Mailing Address - Phone:818-548-5544
Mailing Address - Fax:
Practice Address - Street 1:1101 N PACIFIC AVE STE 206
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91202-4367
Practice Address - Country:US
Practice Address - Phone:818-548-5544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS59108122300000X, 1223E0200X
NY0529121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice