Provider Demographics
NPI:1699506154
Name:CO, ETHAN (DDS)
Entity type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:
Last Name:CO
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 1:5049 PRINCESS ANNE RD
Mailing Address - Street 2:
Mailing Address - City:LA CANADA
Mailing Address - State:CA
Mailing Address - Zip Code:91011-2424
Mailing Address - Country:US
Mailing Address - Phone:818-415-6578
Mailing Address - Fax:
Practice Address - Street 1:1635 N VICTORY PL
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91502-1645
Practice Address - Country:US
Practice Address - Phone:818-360-1946
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-08
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA110234122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist