Healthcare Provider Details

I. General information

NPI: 1679919997
Provider Name (Legal Business Name): SUSANNA GUKASOV D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2013
Last Update Date: 07/29/2024
Certification Date: 12/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19520 NORDHOFF ST STE 17
NORTHRIDGE CA
91324-2444
US

IV. Provider business mailing address

19520 NORDHOFF ST STE 17
NORTHRIDGE CA
91324-2444
US

V. Phone/Fax

Practice location:
  • Phone: 818-565-0057
  • Fax:
Mailing address:
  • Phone: 818-701-9400
  • Fax: 818-557-4911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number61455
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: