1811042203 NPI number — ROBERTO DER BOGHOSIAN DDS A PROFESSIONAL DENTAL CORPORATION

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811042203 NPI number — ROBERTO DER BOGHOSIAN DDS A PROFESSIONAL DENTAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROBERTO DER BOGHOSIAN DDS A PROFESSIONAL DENTAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1811042203
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6812 WOODMAN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VAN NUYS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91405-4208
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-785-7400
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7643 ATLANTIC AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CUDAHY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90201-5019
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-773-7707
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DER BOGHOSIAN
Authorized Official First Name:
ROBERTO
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
323-773-7707

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  31245 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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