Healthcare Provider Details

I. General information

NPI: 1003292145
Provider Name (Legal Business Name): VICKIE LAI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2015
Last Update Date: 07/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4405 W RIVERSIDE DR STE 300
BURBANK CA
91505-4050
US

IV. Provider business mailing address

148 W LA SIERRA DR
ARCADIA CA
91007-4021
US

V. Phone/Fax

Practice location:
  • Phone: 818-846-3831
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number64816
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: