Provider Demographics
NPI:1679606289
Name:SUSTAITA, ANTONIO CANALES (DDS)
Entity type:Individual
Prefix:DR
First Name:ANTONIO
Middle Name:CANALES
Last Name:SUSTAITA
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 1:4633 WHITTIER BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90022-3007
Mailing Address - Country:US
Mailing Address - Phone:323-264-4400
Mailing Address - Fax:323-264-4457
Practice Address - Street 1:4633 WHITTIER BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90022-3007
Practice Address - Country:US
Practice Address - Phone:323-264-4400
Practice Address - Fax:323-264-4457
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA284951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice