Provider Demographics
NPI:1871637165
Name:EKIZIAN, GREG MICHAEL (D,D,S,)
Entity Type:Individual
Prefix:DR
First Name:GREG
Middle Name:MICHAEL
Last Name:EKIZIAN
Suffix:
Gender:M
Credentials:D,D,S,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5363 BALBOA BLVD
Mailing Address - Street 2:SUITE 531
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-2805
Mailing Address - Country:US
Mailing Address - Phone:818-788-6588
Mailing Address - Fax:
Practice Address - Street 1:5363 BALBOA BLVD
Practice Address - Street 2:SUITE 531
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-2805
Practice Address - Country:US
Practice Address - Phone:818-788-6588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA290431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice