Healthcare Provider Details

I. General information

NPI: 1720890783
Provider Name (Legal Business Name): DIWANA MARIE T LUCERO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2025
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

154 W FOOTHILL BLVD STE 2A
MONROVIA CA
91016-2171
US

IV. Provider business mailing address

154 W FOOTHILL BLVD STE 2A
MONROVIA CA
91016-2171
US

V. Phone/Fax

Practice location:
  • Phone: 626-263-3333
  • Fax:
Mailing address:
  • Phone: 626-263-3333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number112724
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: