Healthcare Provider Details

I. General information

NPI: 1861470544
Provider Name (Legal Business Name): BRIAN A LASSITER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 W LA VETA AVE STE 202
ORANGE CA
92868-4402
US

IV. Provider business mailing address

705 W LA VETA AVE STE 202
ORANGE CA
92868-4402
US

V. Phone/Fax

Practice location:
  • Phone: 714-997-2735
  • Fax: 714-997-9022
Mailing address:
  • Phone: 714-997-2735
  • Fax: 714-997-9022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number30834
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: