Provider Demographics
NPI:1639602428
Name:BAYRAKDARIAN CLOVIS I, D.M.D., INC., A PROFESSIONAL DENTAL CORPORATION
Entity Type:Organization
Organization Name:BAYRAKDARIAN CLOVIS I, D.M.D., INC., A PROFESSIONAL DENTAL CORPORATION
Other - Org Name:UNIQUE ORTHODONTICS
Other - Org Type:Other Name
Authorized Official - Title/Position:CREDENTIAL COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BURUCA
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:559-837-1066
Mailing Address - Street 1:427 W NEES AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93611-4434
Mailing Address - Country:US
Mailing Address - Phone:559-297-2121
Mailing Address - Fax:559-322-1306
Practice Address - Street 1:451 CLOVIS AVE STE 105
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93612-1197
Practice Address - Country:US
Practice Address - Phone:559-298-4322
Practice Address - Fax:559-298-5827
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-07
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA500371223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty