Healthcare Provider Details

I. General information

NPI: 1285403436
Provider Name (Legal Business Name): SUSANNA GUKASOV DDS PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2023
Last Update Date: 01/12/2024
Certification Date: 01/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19520 NORDHOFF ST STE 17
NORTHRIDGE CA
91324-2444
US

IV. Provider business mailing address

18746 MAPLEWOOD LN
PORTER RANCH CA
91326-3927
US

V. Phone/Fax

Practice location:
  • Phone: 818-701-9400
  • Fax:
Mailing address:
  • Phone: 323-369-2493
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SUSANNA GUKASOV
Title or Position: DENTIST
Credential: DDS
Phone: 323-369-2493