Healthcare Provider Details

I. General information

NPI: 1912188814
Provider Name (Legal Business Name): ELENITA B. LIWANAG DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2007
Last Update Date: 11/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

144 W CARSON ST
CARSON CA
90745-2601
US

IV. Provider business mailing address

144 W CARSON ST
CARSON CA
90745-2601
US

V. Phone/Fax

Practice location:
  • Phone: 310-835-4088
  • Fax: 310-835-8488
Mailing address:
  • Phone: 310-835-4088
  • Fax: 310-835-8488

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number38963
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: