MEDICARE: DR. DANI LAKSANA 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	1223G0001X	General Practice Dentistry	42348	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	B4234801	OTHER	CA	MEDI CAL DENTI CAL

General Provider Information

NPI Number	:	1457421752
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DANI LAKSANA DDS

Provider Business Mailing Address
First Line	:	4426 APPIAN WAY
Second Line	:
City	:	EL SOBRANTE
State	:	CA
Zip	:	94803-2208
Country	:	US
Telephone Number	:	510-222-1621
Fax Number	:	510-222-1626

Provider Business Practice Location Address
First Line	:	4426 APPIAN WAY
Second Line	:
City	:	EL SOBRANTE
State	:	CA
Zip	:	94803-2208
Country	:	US
Telephone Number	:	510-222-1621
Fax Number	:	510-222-1626

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

Provider Enumeration Date	:	11/08/2006
Last Update Date	:	07/08/2007

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