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General NPI Number Information
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NPI Number | 1831383140
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Entity Type | Organization
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Legal Business Name | LARISSA GUSHANSKY DDS, INC.
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Dates
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Enumeration Date | 08/29/2007
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Last Update Date | 08/29/2007
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Provider Practice Location Address
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Address Line | 3175 FIRESTONE BLVD SUITE200
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City | SOUTH GATE
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State | CA
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Zip | 90280-2951
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Country | US
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Telephone | 323-563-9124
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Fax | 323-563-9814
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Provider Business Mailing Address
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Address Line | 3175 FIRESTONE BLVD SUITE200
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City | SOUTH GATE
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State | CA
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Zip | 90280-2951
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Country | US
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Telephone | 323-563-9124
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Fax | 323-563-9814
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. LARISSA GUSHANSKY
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Credential | D.D.S.
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Telephone | 323-563-9124
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 36156
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License Number State | CA
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