Provider Demographics
NPI:1730307075
Name:BOGHOSSIAN, AVEDIS V (DDS)
Entity Type:Individual
Prefix:
First Name:AVEDIS
Middle Name:V
Last Name:BOGHOSSIAN
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 1:430 S CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-1602
Mailing Address - Country:US
Mailing Address - Phone:818-241-6598
Mailing Address - Fax:818-241-6599
Practice Address - Street 1:430 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-1602
Practice Address - Country:US
Practice Address - Phone:818-241-6598
Practice Address - Fax:818-241-6599
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB428071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice