Provider Demographics
NPI:1780706218
Name:KODABAKSHIAN, MEROUJAN (DDS)
Entity type:Individual
Prefix:
First Name:MEROUJAN
Middle Name:
Last Name:KODABAKSHIAN
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 1:9029 RESEDA BLVD
Mailing Address - Street 2:STE 211
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91324-3932
Mailing Address - Country:US
Mailing Address - Phone:818-701-6989
Mailing Address - Fax:
Practice Address - Street 1:9029 RESEDA BLVD
Practice Address - Street 2:SUITE #211
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91324-3932
Practice Address - Country:US
Practice Address - Phone:818-701-6989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA361631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice