Provider Demographics
NPI:1992831812
Name:DEUKMEDJIAN, MARK (DDS, MSD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:DEUKMEDJIAN
Suffix:
Gender:M
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12018 LOUISE AVE
Mailing Address - Street 2:
Mailing Address - City:GRANADA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91344-2450
Mailing Address - Country:US
Mailing Address - Phone:818-723-9015
Mailing Address - Fax:
Practice Address - Street 1:11155 TAMPA AVE
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91326-2254
Practice Address - Country:US
Practice Address - Phone:818-360-3636
Practice Address - Fax:818-363-4002
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA437781223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics