Provider Demographics
NPI:1659653970
Name:ANTRANIG KELLEYAN
Entity Type:Organization
Organization Name:ANTRANIG KELLEYAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTRANIG
Authorized Official - Middle Name:GARY
Authorized Official - Last Name:KELLEYAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:626-960-6616
Mailing Address - Street 1:13734 RAMONA BLVD
Mailing Address - Street 2:
Mailing Address - City:BALDWIN PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91706-4021
Mailing Address - Country:US
Mailing Address - Phone:626-960-6616
Mailing Address - Fax:626-337-0047
Practice Address - Street 1:13734 RAMONA BLVD
Practice Address - Street 2:
Practice Address - City:BALDWIN PARK
Practice Address - State:CA
Practice Address - Zip Code:91706-4021
Practice Address - Country:US
Practice Address - Phone:626-960-6616
Practice Address - Fax:626-337-0047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-13
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA524091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty