Provider Demographics
NPI:1710556550
Name:WESTERNOFF DMD MD & MARDIROSIAN DDS MD GP-W
Entity Type:Organization
Organization Name:WESTERNOFF DMD MD & MARDIROSIAN DDS MD GP-W
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL SURGEON
Authorized Official - Prefix:
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MARDIROSIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS, MD
Authorized Official - Phone:310-375-0514
Mailing Address - Street 1:1706 S ELENA AVE STE A
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-5715
Mailing Address - Country:US
Mailing Address - Phone:310-375-0514
Mailing Address - Fax:
Practice Address - Street 1:8540 S SEPULVEDA BLVD STE 1206
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-3819
Practice Address - Country:US
Practice Address - Phone:310-375-0514
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-24
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty