Provider Demographics
NPI:1043344591
Name:VARDANIAN, TIGRAN (DDS)
Entity type:Individual
Prefix:DR
First Name:TIGRAN
Middle Name:
Last Name:VARDANIAN
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 1:1720 STONE CANYON DR
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-4041
Mailing Address - Country:US
Mailing Address - Phone:916-759-1574
Mailing Address - Fax:
Practice Address - Street 1:8445 SIERRA COLLEGE BLVD STE B
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-9425
Practice Address - Country:US
Practice Address - Phone:916-759-1574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA442721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD44272Medicaid