=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285403436
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUSANNA GUKASOV DDS PROFESSIONAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/29/2023
-----------------------------------------------------
Last Update Date | 01/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19520 NORDHOFF ST STE 17
-----------------------------------------------------
City | NORTHRIDGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91324-2444
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-701-9400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18746 MAPLEWOOD LN
-----------------------------------------------------
City | PORTER RANCH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91326-3927
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-369-2493
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | SUSANNA GUKASOV
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 323-369-2493
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------