Basic Information
| Provider Information | |||||||||
| NPI: | 1063998359 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | B. DEIRMENJIAN, DDS, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SMILES WEST | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12640 HESPERIA RD STE A | ||||||||
| Address2: | |||||||||
| City: | VICTORVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923957753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602413336 | ||||||||
| FaxNumber: | 7602416496 | ||||||||
| Practice Location | |||||||||
| Address1: | 1451 N MONTEBELLO BLVD | ||||||||
| Address2: | |||||||||
| City: | MONTEBELLO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906402584 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3237249955 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2018 | ||||||||
| LastUpdateDate: | 08/31/2021 | ||||||||
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| AuthorizedOfficialLastName: | DEIRMENJIAN | ||||||||
| AuthorizedOfficialFirstName: | BAROUIR | ||||||||
| AuthorizedOfficialMiddleName: | ARSHAG | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/CEO | ||||||||
| AuthorizedOfficialTelephone: | 3104972211 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 40804 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.