1104987445 NPI number — EVAZYAN DENTAL CORP

Table of content: (NPI 1104987445)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104987445 NPI number — EVAZYAN DENTAL CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EVAZYAN DENTAL CORP
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:
MAGNOLIA GENTLE DENTISTRY
Provider Other Organization Name Type Code:
3
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:
1104987445
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/04/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12143 MAGNOLIA BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VALLEY VILLAGE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91607-2609
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-506-0100
Provider Business Mailing Address Fax Number:
818-506-0700

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12143 MAGNOLIA BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VALLEY VILLAGE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91607-2609
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-506-0100
Provider Business Practice Location Address Fax Number:
818-506-0700
Provider Enumeration Date:
12/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
EVAZYAN
Authorized Official First Name:
BENITA
Authorized Official Middle Name:
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
818-506-0100

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  47472 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 122300000X , with the licence number: 43949 , 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)





Copyright © 2007-2024 www.npivalidator.com