Provider Demographics
NPI:1760635619
Name:TATIANA MIKAELIAN DDS INC
Entity Type:Organization
Organization Name:TATIANA MIKAELIAN DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TATIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:MIKAELIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:213-840-3229
Mailing Address - Street 1:7441 DONNA AVE
Mailing Address - Street 2:
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-2508
Mailing Address - Country:US
Mailing Address - Phone:213-840-3229
Mailing Address - Fax:818-705-4066
Practice Address - Street 1:1209 N. CENTRAL AVE
Practice Address - Street 2:#203
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91202
Practice Address - Country:US
Practice Address - Phone:213-840-3229
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-23
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53716122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG94151-01OtherDENTICAL