Healthcare Provider Details

I. General information

NPI: 1316117104
Provider Name (Legal Business Name): MICHAEL VINCENT LAUREOLA DDS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2008
Last Update Date: 06/08/2023
Certification Date: 06/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3820 SEPULVEDA BLVD
TORRANCE CA
90505-2408
US

IV. Provider business mailing address

12121 WILSHIRE BLVD STE 1111
LOS ANGELES CA
90025-1188
US

V. Phone/Fax

Practice location:
  • Phone: 310-792-5200
  • Fax: 310-792-5201
Mailing address:
  • Phone: 310-820-9933
  • Fax: 310-820-0408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number55121
License Number StateCA

VIII. Authorized Official

Name: DR. MICHAEL VINCENT LAUREOLA
Title or Position: PRESIDENT
Credential:
Phone: 310-792-5200