Basic Information
| Provider Information | |||||||||
| NPI: | 1871192112 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BAROUIR DEIRMENJIAN DENTAL CORPORATION | ||||||||
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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: | 3820 CONVOY ST | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921113722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8585691100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2020 | ||||||||
| LastUpdateDate: | 03/02/2021 | ||||||||
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| AuthorizedOfficialLastName: | DEIRMENJIAN | ||||||||
| AuthorizedOfficialFirstName: | BAROUIR | ||||||||
| AuthorizedOfficialMiddleName: | ARSHAG | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/CEO | ||||||||
| AuthorizedOfficialTelephone: | 3104972211 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/02/2021 | ||||||||
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 | 1223S0112X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Oral and Maxillofacial Surgery | 1223G0001X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.