Provider Demographics
NPI:1063597417
Name:GEVORGIAN, EDITH (DDS)
Entity type:Individual
Prefix:DR
First Name:EDITH
Middle Name:
Last Name:GEVORGIAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:332 E GLENOAKS BLVD
Mailing Address - Street 2:#100
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91207
Mailing Address - Country:US
Mailing Address - Phone:818-244-2181
Mailing Address - Fax:818-244-2959
Practice Address - Street 1:332 E GLENOAKS BLVD
Practice Address - Street 2:#100
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91207
Practice Address - Country:US
Practice Address - Phone:818-244-2181
Practice Address - Fax:818-244-2959
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA373321223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics