Provider Demographics
NPI:1679965537
Name:MATEVOSYAN, YERVAND
Entity Type:Individual
Prefix:
First Name:YERVAND
Middle Name:
Last Name:MATEVOSYAN
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 1:7749 AGATE BEACH WAY
Mailing Address - Street 2:
Mailing Address - City:ANTELOPE
Mailing Address - State:CA
Mailing Address - Zip Code:95843-6036
Mailing Address - Country:US
Mailing Address - Phone:916-844-4004
Mailing Address - Fax:
Practice Address - Street 1:7749 AGATE BEACH WAY
Practice Address - Street 2:
Practice Address - City:ANTELOPE
Practice Address - State:CA
Practice Address - Zip Code:95843-6036
Practice Address - Country:US
Practice Address - Phone:916-844-4004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-02
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA562124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist