Healthcare Provider Details

I. General information

NPI: 1891860912
Provider Name (Legal Business Name): LALISA YAOWARATTANA DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 02/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22737 BARTON RD STE 12
GRAND TERRACE CA
92313-5201
US

IV. Provider business mailing address

22737 BARTON RD STE 12
GRAND TERRACE CA
92313-5201
US

V. Phone/Fax

Practice location:
  • Phone: 909-825-3000
  • Fax: 909-509-5903
Mailing address:
  • Phone: 909-825-3000
  • Fax: 909-509-5903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number52133
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: