Provider Demographics
NPI:1164585832
Name:ANGELA AYZIN DDS AND VAN AYZIN DDS A DENTAL COPORATION
Entity Type:Organization
Organization Name:ANGELA AYZIN DDS AND VAN AYZIN DDS A DENTAL COPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:YAN
Authorized Official - Middle Name:
Authorized Official - Last Name:AYZIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:818-240-5800
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41813122300000X
CA34050122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG9296401Medicaid