Provider Demographics
NPI:1053885020
Name:AVETISYAN, EDUARD (DDS)
Entity type:Individual
Prefix:DR
First Name:EDUARD
Middle Name:
Last Name:AVETISYAN
Suffix:
Gender:
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5300 SANTA MONICA BLVD STE 206
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90029-1258
Mailing Address - Country:US
Mailing Address - Phone:323-798-5271
Mailing Address - Fax:
Practice Address - Street 1:5300 SANTA MONICA BLVD STE 206
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90029-1258
Practice Address - Country:US
Practice Address - Phone:323-798-5271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-14
Last Update Date:2025-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103419122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist