Provider Demographics
NPI:1912734955
Name:AVAGYAN, SUSANNA (DDS)
Entity type:Individual
Prefix:
First Name:SUSANNA
Middle Name:
Last Name:AVAGYAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12733 ARCHWOOD ST
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91606-1213
Mailing Address - Country:US
Mailing Address - Phone:323-829-0055
Mailing Address - Fax:
Practice Address - Street 1:2220 FOOTHILL BLVD STE A
Practice Address - Street 2:
Practice Address - City:LA CANADA FLINTRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91011-1413
Practice Address - Country:US
Practice Address - Phone:818-248-1021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-16
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA110406122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist