Provider Demographics
NPI:1861682759
Name:DR. YURY B. GEYLIKMAN, A PROFESSIONAL DENTAL CORPORATION
Entity Type:Organization
Organization Name:DR. YURY B. GEYLIKMAN, A PROFESSIONAL DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:YURY
Authorized Official - Middle Name:B
Authorized Official - Last Name:GEYLIKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, PHD
Authorized Official - Phone:323-656-9111
Mailing Address - Street 1:3940 LAUREL CANYON BLVD
Mailing Address - Street 2:#388
Mailing Address - City:STUDIO CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91604-3709
Mailing Address - Country:US
Mailing Address - Phone:323-656-9111
Mailing Address - Fax:323-650-9669
Practice Address - Street 1:1745 W AVENUE K
Practice Address - Street 2:SUITE C
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-6501
Practice Address - Country:US
Practice Address - Phone:323-656-9111
Practice Address - Fax:323-650-9669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-27
Last Update Date:2015-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA412551223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB41255-01OtherDENTICAL