1508281387 NPI number — ANDRE ELIASIAN 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 1508281387 NPI number — ANDRE ELIASIAN DENTAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANDRE ELIASIAN 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:
1508281387
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/03/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
290 E VERDUGO AVE
Provider Second Line Business Mailing Address:
208
Provider Business Mailing Address City Name:
BURBANK
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91502-1300
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-861-7427
Provider Business Mailing Address Fax Number:
818-861-7426

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1224 STANLEY AVE UNIT 10
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLENDALE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91206-5629
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-632-5005
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/03/2014

Additional Information

Authorized Official

Authorized Official Last Name:
ELIASIAN
Authorized Official First Name:
ANDRE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/DENTIST
Authorized Official Telephone Number:
818-632-5005

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  62927 , 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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