Provider Demographics
NPI:1528946472
Name:WASSILIAN, VANA
Entity type:Individual
Prefix:
First Name:VANA
Middle Name:
Last Name:WASSILIAN
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3624 WESTWOOD BLVD APT 200
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034-6710
Mailing Address - Country:US
Mailing Address - Phone:559-801-1826
Mailing Address - Fax:
Practice Address - Street 1:1101 TRUMAN ST
Practice Address - Street 2:
Practice Address - City:SAN FERNANDO
Practice Address - State:CA
Practice Address - Zip Code:91340-3237
Practice Address - Country:US
Practice Address - Phone:818-493-4312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-26
Last Update Date:2025-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1121121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice