=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265543920
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDREI SOUCHITSKI SR. DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2006
-----------------------------------------------------
Last Update Date | 04/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 514 E WASHINGTON BLVD
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90015-3723
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-749-3934
-----------------------------------------------------
Fax | 213-749-0994
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 514 E WASHINGTON BLVD
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90015-3723
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-749-3934
-----------------------------------------------------
Fax | 213-749-0994
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 43249
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------