Healthcare Provider Details

I. General information

NPI: 1366798530
Provider Name (Legal Business Name): KONGSAB LA HATLAVONGSA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2012
Last Update Date: 03/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 BARBOZA ST
MENDOTA CA
93640-1901
US

IV. Provider business mailing address

3035 N MCARTHUR AVE
FRESNO CA
93727
US

V. Phone/Fax

Practice location:
  • Phone: 559-655-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number61581
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: