Basic Information
| Provider Information | |||||||||
| NPI: | 1104425370 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JACK BAYRAYMYAN DENTAL GROUP INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2221 E BIJOU ST STE 100 | ||||||||
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| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809098009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195761850 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2621 ZOE AVE STE A | ||||||||
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| City: | HUNTINGTON PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902554131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195761850 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2020 | ||||||||
| LastUpdateDate: | 10/20/2020 | ||||||||
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| AuthorizedOfficialLastName: | URBANOZO | ||||||||
| AuthorizedOfficialFirstName: | SHAUN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7193232362 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | JACK BAYRAMYAN DENTAL GROUP INC. | ||||||||
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| NPICertificationDate: | 10/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223X0400X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics |
No ID Information.