Provider Demographics
NPI:1184771818
Name:ROSTOMIAN, SOUREN A (DDS)
Entity type:Individual
Prefix:DR
First Name:SOUREN
Middle Name:A
Last Name:ROSTOMIAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:ALEXANDER
Other - Middle Name:S
Other - Last Name:ROSS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:6300 SAN FERNANDO RD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91201-2414
Mailing Address - Country:US
Mailing Address - Phone:818-547-4455
Mailing Address - Fax:818-547-9955
Practice Address - Street 1:6300 SAN FERNANDO RD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91201-2414
Practice Address - Country:US
Practice Address - Phone:818-547-4455
Practice Address - Fax:818-547-9955
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA445341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG9307801Medicaid