Healthcare Provider Details

I. General information

NPI: 1013126648
Provider Name (Legal Business Name): LYTLE, TATE & STAMPER, A DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1370 FOOTHILL BLVD SUITE 200
LA CANADA CA
91011-2150
US

IV. Provider business mailing address

1370 FOOTHILL BLVD SUITE 200
LA CANADA CA
91011-2150
US

V. Phone/Fax

Practice location:
  • Phone: 818-952-8183
  • Fax: 818-952-6437
Mailing address:
  • Phone: 818-952-8183
  • Fax: 818-952-6437

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: MS. CHERYL A ZAKARIAN
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 818-952-8183