Provider Demographics
NPI:1003047341
Name:GAZARIAN-BOUSTANI, LYLA A (DDS)
Entity Type:Individual
Prefix:DR
First Name:LYLA
Middle Name:A
Last Name:GAZARIAN-BOUSTANI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4904 VENTURA CANYON AVE
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91423-1408
Mailing Address - Country:US
Mailing Address - Phone:818-635-9358
Mailing Address - Fax:
Practice Address - Street 1:230 N MARYLAND AVE
Practice Address - Street 2:SUITE 206
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4261
Practice Address - Country:US
Practice Address - Phone:818-547-2804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-04
Last Update Date:2009-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA567171223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics