Provider Demographics
NPI:1679780464
Name:KAREN BAGHDASARYAN DENTAL CORPORATION
Entity Type:Organization
Organization Name:KAREN BAGHDASARYAN DENTAL CORPORATION
Other - Org Name:CYBERDENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:BAGHDASARYAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:818-547-4455
Mailing Address - Street 1:6300 SAN FERNANDO RD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91201-2414
Mailing Address - Country:US
Mailing Address - Phone:818-547-4455
Mailing Address - Fax:818-547-9955
Practice Address - Street 1:6300 SAN FERNANDO RD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91201-2414
Practice Address - Country:US
Practice Address - Phone:818-547-4455
Practice Address - Fax:818-547-9955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA504091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG9307801Medicaid
CAG9834801OtherBILLING PROVIDER