Healthcare Provider Details

I. General information

NPI: 1346320975
Provider Name (Legal Business Name): SUSSAN CHANIZI DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 FRESNO ST SUITE 300
FRESNO CA
93721-1708
US

IV. Provider business mailing address

105 E SIERRA AVE APT 123
FRESNO CA
93710-3600
US

V. Phone/Fax

Practice location:
  • Phone: 559-442-1100
  • Fax:
Mailing address:
  • Phone: 559-431-2937
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number50449
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: