Provider Demographics
NPI:1801565429
Name:BOGOSIAN, NINELLA
Entity type:Individual
Prefix:
First Name:NINELLA
Middle Name:
Last Name:BOGOSIAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1129 MELROSE AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91202-2433
Mailing Address - Country:US
Mailing Address - Phone:818-858-4406
Mailing Address - Fax:
Practice Address - Street 1:1129 MELROSE AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91202-2433
Practice Address - Country:US
Practice Address - Phone:818-858-4406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-08
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1060021223G0001X
CADDS1060021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice