=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508112285
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EDIT AVODIAN DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/31/2012
-----------------------------------------------------
Last Update Date | 02/13/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4322 45TH ST APT 4A
-----------------------------------------------------
City | SUNNYSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11104-2349
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-269-6610
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4322 45TH ST APT 4A
-----------------------------------------------------
City | SUNNYSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11104-2349
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-269-6610
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 056126
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 62142
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------