Basic Information
| Provider Information | |||||||||
| NPI: | 1871053348 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | B. DEIRMENJIAN, DDS, 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: | 8463 HAVEN AVE | ||||||||
| Address2: | |||||||||
| City: | RANCHO CUCAMONGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917303845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9094810025 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2019 | ||||||||
| LastUpdateDate: | 03/21/2019 | ||||||||
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| AuthorizedOfficialLastName: | DEIRMENJIAN | ||||||||
| AuthorizedOfficialFirstName: | BAROUIR | ||||||||
| AuthorizedOfficialMiddleName: | ARSHAG | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/CEO | ||||||||
| AuthorizedOfficialTelephone: | 3104972211 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | B. DEIRMENJIAN, DDS, INC | ||||||||
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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 | 1223P0221X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Pediatric Dentistry | 1223P0300X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Periodontics | 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.