Provider Demographics
NPI:1710035910
Name:OHANNESSIAN, MANUEL JEAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MANUEL
Middle Name:JEAN
Last Name:OHANNESSIAN
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:PO BOX 312
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92402-0312
Mailing Address - Country:US
Mailing Address - Phone:909-386-3650
Mailing Address - Fax:909-386-3690
Practice Address - Street 1:654 W 4TH ST STE A
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92410-3216
Practice Address - Country:US
Practice Address - Phone:909-386-3650
Practice Address - Fax:909-386-3690
Is Sole Proprietor?:No
Enumeration Date:2007-01-06
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA 54182122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist