Provider Demographics
NPI:1649984865
Name:SHANT TERTERYAN DDS INC
Entity type:Organization
Organization Name:SHANT TERTERYAN DDS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANT
Authorized Official - Middle Name:
Authorized Official - Last Name:TERTERYAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:818-665-5113
Mailing Address - Street 1:3145 KINGRIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91206-1028
Mailing Address - Country:US
Mailing Address - Phone:818-665-5113
Mailing Address - Fax:
Practice Address - Street 1:10436 SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:MISSION HILLS
Practice Address - State:CA
Practice Address - Zip Code:91345-2424
Practice Address - Country:US
Practice Address - Phone:818-830-2828
Practice Address - Fax:818-232-3083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-11
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Multi-Specialty