Provider Demographics
NPI:1801929393
Name:MIKAELIAN, TATIANA (DDS)
Entity type:Individual
Prefix:DR
First Name:TATIANA
Middle Name:
Last Name:MIKAELIAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:TATIANA
Other - Middle Name:L
Other - Last Name:LERNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:10455 LOWER AZUSA RD
Mailing Address - Street 2:
Mailing Address - City:TEMPLE CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91780-3470
Mailing Address - Country:US
Mailing Address - Phone:626-444-3744
Mailing Address - Fax:626-444-3944
Practice Address - Street 1:1209 N CENTRAL AVE APT 203
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91202-3180
Practice Address - Country:US
Practice Address - Phone:213-840-3229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA537161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG94151-01OtherDENTICAL