Provider Demographics
NPI:1023443454
Name:ELIASIAN, ANDRE (DDS)
Entity type:Individual
Prefix:
First Name:ANDRE
Middle Name:
Last Name:ELIASIAN
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 1:1249 W GLENOAKS BLVD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91201-2238
Mailing Address - Country:US
Mailing Address - Phone:818-649-1772
Mailing Address - Fax:818-649-1774
Practice Address - Street 1:1249 W GLENOAKS BLVD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91201-2238
Practice Address - Country:US
Practice Address - Phone:818-649-1772
Practice Address - Fax:818-649-1774
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-04
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA629271223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice