Provider Demographics
NPI:1992179006
Name:YEGHISHEH MIRZOYAN D.D.S., INC.
Entity Type:Organization
Organization Name:YEGHISHEH MIRZOYAN D.D.S., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:YEGHISHEH
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRZOYAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:818-419-0047
Mailing Address - Street 1:6440 GREENBUSH AVE
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91401-1839
Mailing Address - Country:US
Mailing Address - Phone:818-403-7655
Mailing Address - Fax:818-547-5510
Practice Address - Street 1:14435 SHERMAN WAY STE 110
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-6229
Practice Address - Country:US
Practice Address - Phone:818-927-3113
Practice Address - Fax:818-547-5510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA122300000X
CA637611223G0001X
CA445341223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1497156038Medicaid
CA1184771818Medicaid