Provider Demographics
NPI:1548478399
Name:GUSHANSKY, LARISSA (DDS)
Entity type:Individual
Prefix:DR
First Name:LARISSA
Middle Name:
Last Name:GUSHANSKY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:LARISSA
Other - Middle Name:
Other - Last Name:GUSHANSKY, DDS, INC.
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:211 GLENROY PL
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-2419
Mailing Address - Country:US
Mailing Address - Phone:310-951-9500
Mailing Address - Fax:310-988-2957
Practice Address - Street 1:3175 FIRESTONE BLVD # 200
Practice Address - Street 2:
Practice Address - City:SOUTH GATE
Practice Address - State:CA
Practice Address - Zip Code:90280-2951
Practice Address - Country:US
Practice Address - Phone:323-563-9124
Practice Address - Fax:323-563-9814
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA361561223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB36156-01Medicaid
CAB36156-02Medicaid