Healthcare Provider Details

I. General information

NPI: 1588801674
Provider Name (Legal Business Name): LAWRENCE WENCESLAO SARAOS RDA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2009
Last Update Date: 01/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1406 N AZUSA AVE SUITE C
COVINA CA
91722-1257
US

IV. Provider business mailing address

12121 WILSHIRE BLVD SUITE 1111
LOS ANGELES CA
90025-1123
US

V. Phone/Fax

Practice location:
  • Phone: 626-858-9940
  • Fax:
Mailing address:
  • Phone: 310-820-9933
  • Fax: 310-820-0408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number65767
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: