Provider Demographics
NPI:1992082960
Name:B. DEIRMENJIAN, DDS, INC.
Entity type:Organization
Organization Name:B. DEIRMENJIAN, DDS, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:BAROUIR
Authorized Official - Middle Name:
Authorized Official - Last Name:DEIRMENJIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-923-6981
Mailing Address - Street 1:260 S GLENDORA AVE
Mailing Address - Street 2:200
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-3041
Mailing Address - Country:US
Mailing Address - Phone:626-214-1900
Mailing Address - Fax:626-214-1954
Practice Address - Street 1:12940 FOOTHILL BLVD.
Practice Address - Street 2:C
Practice Address - City:SN FERNANDO
Practice Address - State:CA
Practice Address - Zip Code:91340
Practice Address - Country:US
Practice Address - Phone:818-408-5100
Practice Address - Fax:818-408-5111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-04
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40804122300000X
1223E0200X, 1223G0001X, 1223P0221X, 1223P0300X, 1223S0112X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1225097215Medicaid