Provider Demographics
NPI:1699831065
Name:DERBOGHOSIAN ITUTMAZIAN, RUPEN (DDS)
Entity Type:Individual
Prefix:
First Name:RUPEN
Middle Name:
Last Name:DERBOGHOSIAN ITUTMAZIAN
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 1:75 PONCETTA DR APT 327
Mailing Address - Street 2:
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94015-4810
Mailing Address - Country:US
Mailing Address - Phone:818-350-3451
Mailing Address - Fax:
Practice Address - Street 1:6812 WOODMAN AVE
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-4208
Practice Address - Country:US
Practice Address - Phone:818-350-3451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA552261223G0001X
NV5411122300000X
RICDEN03106122300000X
NH03895122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist