Provider Demographics
NPI:1821464801
Name:MIKAYELYAN, MISAK (DDS)
Entity Type:Individual
Prefix:
First Name:MISAK
Middle Name:
Last Name:MIKAYELYAN
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 1:702 W BROADWAY
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-1010
Mailing Address - Country:US
Mailing Address - Phone:818-649-1980
Mailing Address - Fax:818-484-4747
Practice Address - Street 1:702 W BROADWAY
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-1010
Practice Address - Country:US
Practice Address - Phone:818-688-1453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-13
Last Update Date:2017-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS647531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice