Healthcare Provider Details

I. General information

NPI: 1093623233
Provider Name (Legal Business Name): LASSAK GLOW
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2026
Last Update Date: 08/29/2026
Certification Date: 08/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13606 ROSCOE BLVD UNIT P3
PANORAMA CITY CA
91402-3906
US

IV. Provider business mailing address

13606 ROSCOE BLVD UNIT P3
PANORAMA CITY CA
91402-3906
US

V. Phone/Fax

Practice location:
  • Phone: 747-321-1509
  • Fax:
Mailing address:
  • Phone: 747-321-1509
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: LUCIA LASSAKOVA
Title or Position: OWNER
Credential:
Phone: 747-321-1509