Provider Demographics
NPI:1316130123
Name:YEGHIASARIAN, LARA MESROB (DMD)
Entity type:Individual
Prefix:DR
First Name:LARA
Middle Name:MESROB
Last Name:YEGHIASARIAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7010 MORRISON AVE BLDG 128
Mailing Address - Street 2:DENTAL ACTIVITY
Mailing Address - City:FORT BENNING
Mailing Address - State:GA
Mailing Address - Zip Code:31905-0102
Mailing Address - Country:US
Mailing Address - Phone:706-544-4530
Mailing Address - Fax:
Practice Address - Street 1:7010 MORRISON AVE BLDG 128
Practice Address - Street 2:DENTAL ACTIVITY
Practice Address - City:FORT BENNING
Practice Address - State:GA
Practice Address - Zip Code:31905-0102
Practice Address - Country:US
Practice Address - Phone:706-544-4530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-24
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9528122300000X
PADS0448491223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist