Provider Demographics
NPI:1073710240
Name:AYZIN, YAN (DDS)
Entity Type:Individual
Prefix:MR
First Name:YAN
Middle Name:
Last Name:AYZIN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 SO CENTRAL AVE
Mailing Address - Street 2:SUITE #10
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-2079
Mailing Address - Country:US
Mailing Address - Phone:818-240-5800
Mailing Address - Fax:818-240-5801
Practice Address - Street 1:815 SO CENTRAL AVE
Practice Address - Street 2:SUITE #10
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2079
Practice Address - Country:US
Practice Address - Phone:818-240-5800
Practice Address - Fax:818-240-5801
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34050122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD34050Medicaid