MEDICARE: DR. NORBERTO BRAVO LUPISAN DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	60135	CA

General Provider Information

NPI Number	:	1053604637
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NORBERTO BRAVO LUPISAN DDS

Provider Business Mailing Address
First Line	:	PO BOX 12113
Second Line	:
City	:	LA CRESCENTA
State	:	CA
Zip	:	91224-0813
Country	:	US
Telephone Number	:	818-248-7126
Fax Number	:

Provider Business Practice Location Address
First Line	:	1131 N VERMONT AVE
Second Line	:	STE. 103
City	:	LOS ANGELES
State	:	CA
Zip	:	90029-1764
Country	:	US
Telephone Number	:	323-913-1352
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/16/2011
Last Update Date	:	09/22/2011

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