MEDICARE: LILYA VAISMANA PROFESSIONAL DENTAL CORP

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		CA

General Provider Information

NPI Number	:	1548278799
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LILYA VAISMANA PROFESSIONAL DENTAL CORP

Provider Business Mailing Address
First Line	:	760 LA PLAYA ST
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94121-3262
Country	:	US
Telephone Number	:	415-221-5592
Fax Number	:	415-221-8826

Provider Business Practice Location Address
First Line	:	760 LA PLAYA ST
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94121-3262
Country	:	US
Telephone Number	:	415-221-5592
Fax Number	:	415-221-8826

Authorized Official
Title or Position	:	PRESIDENT
Name	:	LILYA VAISMAN
Credential	:	DDS
Telephone Number	:	415-221-5592

Provider Enumeration Date	:	08/04/2006
Last Update Date	:	07/21/2022

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