Provider Demographics
NPI:1154931772
Name:GLEN DENTAL STUDIO
Entity type:Organization
Organization Name:GLEN DENTAL STUDIO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HARUTYUNYAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:818-568-6655
Mailing Address - Street 1:146 N BRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-2602
Mailing Address - Country:US
Mailing Address - Phone:818-502-1999
Mailing Address - Fax:
Practice Address - Street 1:146 N BRAND BLVD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-2602
Practice Address - Country:US
Practice Address - Phone:818-502-1999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-07
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental