Provider Demographics
NPI:1679981096
Name:TANIELIAN, ALEX GARO (DDS)
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:GARO
Last Name:TANIELIAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 W JACKSON BLVD STE 1410
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60604-3867
Mailing Address - Country:US
Mailing Address - Phone:312-939-2400
Mailing Address - Fax:
Practice Address - Street 1:111 W JACKSON BLVD STE 1410
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60604-3867
Practice Address - Country:US
Practice Address - Phone:312-939-2400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-29
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61272179122300000X
CA637141223G0001X
IL0190322061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist