Healthcare Provider Details

I. General information

NPI: 1639300668
Provider Name (Legal Business Name): SHAMEIKA LAKAYYAI DOUGLASS R.D.A
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2009
Last Update Date: 08/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

2170 N RANCHO AVE H233
COLTON CA
92324-6900
US

V. Phone/Fax

Practice location:
  • Phone: 310-820-9933
  • Fax:
Mailing address:
  • Phone: 909-885-0372
  • Fax: 909-885-0372

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number73858
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: