Provider Demographics
NPI:1144420795
Name:EVAZYAN, BENITA (DMD)
Entity Type:Individual
Prefix:
First Name:BENITA
Middle Name:
Last Name:EVAZYAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12143 MAGNOLIA BLVD
Mailing Address - Street 2:
Mailing Address - City:VALLEY VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91607-2609
Mailing Address - Country:US
Mailing Address - Phone:818-506-0100
Mailing Address - Fax:818-506-0700
Practice Address - Street 1:12143 MAGNOLIA BLVD
Practice Address - Street 2:
Practice Address - City:VALLEY VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91607-2609
Practice Address - Country:US
Practice Address - Phone:818-506-0100
Practice Address - Fax:818-506-0700
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-23
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47472122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist