Provider Demographics
NPI:1568662617
Name:EVAZYAN, RITA
Entity Type:Individual
Prefix:
First Name:RITA
Middle Name:
Last Name:EVAZYAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4700 INGLEWOOD BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90230-5896
Mailing Address - Country:US
Mailing Address - Phone:310-392-8636
Mailing Address - Fax:
Practice Address - Street 1:4700 INGLEWOOD BLVD STE 102
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90230-5896
Practice Address - Country:US
Practice Address - Phone:310-392-8636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-18
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43949122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist