Healthcare Provider Details

I. General information

NPI: 1275914863
Provider Name (Legal Business Name): LISETTE OLIVIA ALONZO RDA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2015
Last Update Date: 06/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2604 S VERMONT AVE
LOS ANGELES CA
90007-2298
US

IV. Provider business mailing address

7969 CLETA ST
DOWNEY CA
90241-4793
US

V. Phone/Fax

Practice location:
  • Phone: 323-731-3333
  • Fax:
Mailing address:
  • Phone: 562-861-2746
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number689557
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: