Healthcare Provider Details

I. General information

NPI: 1386868503
Provider Name (Legal Business Name): SUSAN MANAVI, DDS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12730 HAWTHORNE BLVD STE D
HAWTHORNE CA
90250-3919
US

IV. Provider business mailing address

12730 HAWTHORNE BLVD STE D
HAWTHORNE CA
90250-3919
US

V. Phone/Fax

Practice location:
  • Phone: 310-644-4000
  • Fax: 310-644-3232
Mailing address:
  • Phone: 310-644-4000
  • Fax: 310-644-3232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number35141
License Number StateCA

VIII. Authorized Official

Name: SUSAN MAANAVI
Title or Position: OWNER
Credential:
Phone: 310-644-4000