Provider Demographics
NPI:1659938470
Name:K. SHAGRAMANOVA DENTAL CORP.
Entity Type:Organization
Organization Name:K. SHAGRAMANOVA DENTAL CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAGRAMANOVA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:818-636-9208
Mailing Address - Street 1:410 W COLORADO ST
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-1504
Mailing Address - Country:US
Mailing Address - Phone:818-956-9907
Mailing Address - Fax:
Practice Address - Street 1:3175 FIRESTONE BLVD # 201
Practice Address - Street 2:
Practice Address - City:SOUTH GATE
Practice Address - State:CA
Practice Address - Zip Code:90280-2951
Practice Address - Country:US
Practice Address - Phone:323-749-0137
Practice Address - Fax:323-749-0334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-28
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty