Basic Information
| Provider Information | |||||||||
| NPI: | 1073026373 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DEIRMENJIAN DENTAL GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12640 HESPERIA RD STE A | ||||||||
| Address2: | |||||||||
| City: | VICTORVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923957753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602413336 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12640 HESPERIA RD STE A | ||||||||
| Address2: | |||||||||
| City: | VICTORVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923957753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602413336 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2017 | ||||||||
| LastUpdateDate: | 09/29/2021 | ||||||||
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| AuthorizedOfficialLastName: | DEIRMENJIAN | ||||||||
| AuthorizedOfficialFirstName: | BAROUIR | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/PROVIDER | ||||||||
| AuthorizedOfficialTelephone: | 7602413336 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
| NPICertificationDate: | 09/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 40804 | CA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist |
No ID Information.