MEDICARE: DR. LISA VALLESTEROS

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	63351	CA

General Provider Information

NPI Number	:	1780004366
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LISA VALLESTEROS

Provider Business Mailing Address
First Line	:	1131 N VERMONT AVE STE 102
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90029-1764
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1131 N VERMONT AVE STE 102
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90029-1764
Country	:	US
Telephone Number	:	323-661-6706
Fax Number	:

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

Provider Enumeration Date	:	04/22/2014
Last Update Date	:	04/22/2014

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