Healthcare Provider Details

I. General information

NPI: 1174056931
Provider Name (Legal Business Name): LAZCANO FAMILY DENTAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2017
Last Update Date: 04/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15355 SHERMAN WAY SUITE P
VAN NUYS CA
91406-4200
US

IV. Provider business mailing address

15355 SHERMAN WAY SUITE P
VAN NUYS CA
91406-4200
US

V. Phone/Fax

Practice location:
  • Phone: 954-205-3183
  • Fax:
Mailing address:
  • Phone: 954-205-3183
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number101016
License Number StateCA

VIII. Authorized Official

Name: MARITZA LAZCANO
Title or Position: GENERAL DENTIST
Credential: DDS
Phone: 954-205-3183