Basic Information
Provider Information | |||||||||
NPI: | 1386305647 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BAROUIR DEIRMENJIAN DENTAL CORPORATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 12640 HESPERIA RD STE A | ||||||||
Address2: |   | ||||||||
City: | VICTORVILLE | ||||||||
State: | CA | ||||||||
PostalCode: | 923957753 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7602413336 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 720 BROOKSIDE AVE STE 101 | ||||||||
Address2: |   | ||||||||
City: | REDLANDS | ||||||||
State: | CA | ||||||||
PostalCode: | 923735189 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9097984111 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/07/2022 | ||||||||
LastUpdateDate: | 01/07/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DEIRMENJIAN | ||||||||
AuthorizedOfficialFirstName: | BAROUIR | ||||||||
AuthorizedOfficialMiddleName: | ARSHAG | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER/CEO | ||||||||
AuthorizedOfficialTelephone: | 3104972211 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/07/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist |   | 1223E0200X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Endodontics | 1223S0112X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Oral and Maxillofacial Surgery | 1223X0400X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics | 1223G0001X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.