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General NPI Number Information
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NPI Number | 1174056931
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Entity Type | Organization
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Legal Business Name | LAZCANO FAMILY DENTAL GROUP
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Dates
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Enumeration Date | 04/09/2017
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Last Update Date | 04/09/2017
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Provider Practice Location Address
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Address Line | 15355 SHERMAN WAY SUITE P
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City | VAN NUYS
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State | CA
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Zip | 91406-4200
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Country | US
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Telephone | 954-205-3183
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Fax |
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Provider Business Mailing Address
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Address Line | 15355 SHERMAN WAY SUITE P
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City | VAN NUYS
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State | CA
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Zip | 91406-4200
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Country | US
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Telephone | 954-205-3183
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Fax |
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Authorized Official
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Title or Position | GENERAL DENTIST
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Name | MARITZA LAZCANO
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Credential | DDS
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Telephone | 954-205-3183
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 101016
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License Number State | CA
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