Provider Demographics
NPI:1770035677
Name:DEIRMENJIAN DENTISTRY INC
Entity Type:Organization
Organization Name:DEIRMENJIAN DENTISTRY INC
Other - Org Name:SMILES WEST OF COVINA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BAROUIR
Authorized Official - Middle Name:
Authorized Official - Last Name:DEIRMENJIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:855-705-3434
Mailing Address - Street 1:15643 SHERMAN WAY
Mailing Address - Street 2:SUITE 220
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91406-4135
Mailing Address - Country:US
Mailing Address - Phone:855-705-3434
Mailing Address - Fax:855-705-3399
Practice Address - Street 1:470 W BADILLO ST
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-1829
Practice Address - Country:US
Practice Address - Phone:626-331-8287
Practice Address - Fax:626-331-5795
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:B DEIRMENJIAN DDS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-27
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40804122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1649498817Medicaid
CA1356560494Medicaid