Provider Demographics
NPI:1215325857
Name:MATEVOSYAN, TAMARA (DDS)
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:MATEVOSYAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3048 FAIRESTA ST
Mailing Address - Street 2:
Mailing Address - City:LA CRESCENTA
Mailing Address - State:CA
Mailing Address - Zip Code:91214
Mailing Address - Country:US
Mailing Address - Phone:818-720-4160
Mailing Address - Fax:
Practice Address - Street 1:3206 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-5553
Practice Address - Country:US
Practice Address - Phone:310-827-6453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-06
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63008122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist