Provider Demographics
NPI:1801519400
Name:AVETISYAN, MELKON (DDS)
Entity type:Individual
Prefix:DR
First Name:MELKON
Middle Name:
Last Name:AVETISYAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:599 INLAND CENTER DR
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-1843
Mailing Address - Country:US
Mailing Address - Phone:909-383-0486
Mailing Address - Fax:
Practice Address - Street 1:815 S DETROIT ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036-4813
Practice Address - Country:US
Practice Address - Phone:626-807-3698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-20
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA108012122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist