Provider Demographics
NPI:1386919553
Name:MARTIROSSIAN, GAIANE (DA)
Entity type:Individual
Prefix:
First Name:GAIANE
Middle Name:
Last Name:MARTIROSSIAN
Suffix:
Gender:F
Credentials:DA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 INTERVALE RD
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02910-5225
Mailing Address - Country:US
Mailing Address - Phone:401-316-4760
Mailing Address - Fax:401-490-2021
Practice Address - Street 1:1220 PONTIAC AVE STE 303
Practice Address - Street 2:
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02920-4457
Practice Address - Country:US
Practice Address - Phone:401-944-5204
Practice Address - Fax:401-490-2021
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-20
Last Update Date:2012-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDA00309171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist