Healthcare Provider Details

I. General information

NPI: 1518651553
Provider Name (Legal Business Name): LAWRENCE CERENO DIMAYUGA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2023
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3580 S EICHLER PASEO UNIT 108
ONTARIO CA
91761-3266
US

IV. Provider business mailing address

3580 S EICHLER PASEO UNIT 108
ONTARIO CA
91761-3266
US

V. Phone/Fax

Practice location:
  • Phone: 714-519-8797
  • Fax:
Mailing address:
  • Phone: 714-519-8797
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number113698
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: