Provider Demographics
NPI:1063799823
Name:MARTIROSYAN, JACKLYN (RDHAP)
Entity type:Individual
Prefix:MRS
First Name:JACKLYN
Middle Name:
Last Name:MARTIROSYAN
Suffix:
Gender:F
Credentials:RDHAP
Other - Prefix:
Other - First Name:ZHAKLIN
Other - Middle Name:
Other - Last Name:MARTIROSYAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3727 W. MAGNOLIA BLVD.
Mailing Address - Street 2:#436
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505
Mailing Address - Country:US
Mailing Address - Phone:818-429-9454
Mailing Address - Fax:
Practice Address - Street 1:3727 W. MAGNOLIA BLVD.
Practice Address - Street 2:#436
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505
Practice Address - Country:US
Practice Address - Phone:818-429-9454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-08
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA380124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist