1639602428 NPI number — BAYRAKDARIAN CLOVIS I, D.M.D., INC., A PROFESSIONAL DENTAL CORPORATION

Table of content: (NPI 1639602428)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639602428 NPI number — BAYRAKDARIAN CLOVIS I, D.M.D., INC., A PROFESSIONAL DENTAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BAYRAKDARIAN CLOVIS I, D.M.D., INC., 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:
6
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:
1639602428
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/01/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
427 W NEES AVE STE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLOVIS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93611-4434
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
559-297-2121
Provider Business Mailing Address Fax Number:
559-322-1306

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
451 CLOVIS AVE STE 105
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLOVIS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93612-1197
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-298-4322
Provider Business Practice Location Address Fax Number:
559-298-5827
Provider Enumeration Date:
04/07/2017

Additional Information

Authorized Official

Authorized Official Last Name:
BURUCA
Authorized Official First Name:
ANGIE
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIAL COORDINATOR
Authorized Official Telephone Number:
559-837-1066

Provider Taxonomy Codes

  • Taxonomy code: 1223X0400X , with the licence number:  50037 , 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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