Healthcare Provider Details

I. General information

NPI: 1538221742
Provider Name (Legal Business Name): MICHAEL VINCENT LAUREOLA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3635 E 1ST ST
LOS ANGELES CA
90063-2345
US

IV. Provider business mailing address

2265 LANGSPUR DR
HACIENDA HEIGHTS CA
91745-5732
US

V. Phone/Fax

Practice location:
  • Phone: 323-269-7367
  • Fax:
Mailing address:
  • Phone: 562-266-7079
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number55121
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: