Healthcare Provider Details

I. General information

NPI: 1710812052
Provider Name (Legal Business Name): NATHANIEL ORLIE LASALLE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2026
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 E COTATI AVE STE A
COTATI CA
94931-4009
US

IV. Provider business mailing address

1371 MIDDLEBROOK WAY
ROHNERT PARK CA
94928-3621
US

V. Phone/Fax

Practice location:
  • Phone: 707-795-6424
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number113094
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: