Provider Demographics
NPI:1801491501
Name:TERVARDANYAN, VAZGEN (RDHAP)
Entity type:Individual
Prefix:
First Name:VAZGEN
Middle Name:
Last Name:TERVARDANYAN
Suffix:
Gender:M
Credentials:RDHAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25115 AVENUE STANFORD STE A-104
Mailing Address - Street 2:
Mailing Address - City:VALENCIA
Mailing Address - State:CA
Mailing Address - Zip Code:91355-1290
Mailing Address - Country:US
Mailing Address - Phone:661-257-2339
Mailing Address - Fax:
Practice Address - Street 1:23772 NEWHALL AVE
Practice Address - Street 2:
Practice Address - City:NEWHALL
Practice Address - State:CA
Practice Address - Zip Code:91321-3125
Practice Address - Country:US
Practice Address - Phone:661-291-1777
Practice Address - Fax:661-255-1208
Is Sole Proprietor?:No
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHAP234124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist