Provider Demographics
NPI:1184173718
Name:ARMEN MARDIROSSIAN PROFESSIONAL DENTAL CORP
Entity type:Organization
Organization Name:ARMEN MARDIROSSIAN PROFESSIONAL DENTAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ARMEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MARDIROSSIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:714-000-0000
Mailing Address - Street 1:13197 CENTRAL AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-4178
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13197 CENTRAL AVE STE 201
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-4178
Practice Address - Country:US
Practice Address - Phone:714-000-0000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-23
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA459191223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty