Provider Demographics
NPI:1568472991
Name:KELLEYAN, ANTRANIG GARY (DDS)
Entity type:Individual
Prefix:DR
First Name:ANTRANIG
Middle Name:GARY
Last Name:KELLEYAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:616 N GARFIELD AVE
Mailing Address - Street 2:SUITE # 404
Mailing Address - City:MONTEREY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91754-1141
Mailing Address - Country:US
Mailing Address - Phone:626-280-4122
Mailing Address - Fax:626-280-4124
Practice Address - Street 1:616 N GARFIELD AVE
Practice Address - Street 2:ST 404
Practice Address - City:MONTEREY PARK
Practice Address - State:CA
Practice Address - Zip Code:91754-1141
Practice Address - Country:US
Practice Address - Phone:626-280-4122
Practice Address - Fax:626-280-4124
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2011-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA524091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice