Provider Demographics
NPI:1780633735
Name:MATEVOSIAN, EDWARD (DDS)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:MATEVOSIAN
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 1:3132 CHADNEY DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91206-1003
Mailing Address - Country:US
Mailing Address - Phone:818-790-2024
Mailing Address - Fax:
Practice Address - Street 1:1690 W ADAMS BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90007-1535
Practice Address - Country:US
Practice Address - Phone:323-730-0924
Practice Address - Fax:323-730-0629
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA416511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB41651-01Medicare ID - Type UnspecifiedDENTI-CAL
CAB41651-02Medicare ID - Type UnspecifiedDENTI-CAL