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General NPI Number Information
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NPI Number | 1891860912
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Entity Type | Individual
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Provider Name | LALISA YAOWARATTANA DDS
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Gender | Female
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Dates
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Enumeration Date | 11/22/2006
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Last Update Date | 02/08/2017
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Provider Practice Location Address
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Address Line | 22737 BARTON RD STE 12
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City | GRAND TERRACE
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State | CA
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Zip | 92313-5201
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Country | US
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Telephone | 909-825-3000
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Fax | 909-509-5903
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Provider Business Mailing Address
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Address Line | 22737 BARTON RD STE 12
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City | GRAND TERRACE
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State | CA
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Zip | 92313-5201
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Country | US
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Telephone | 909-825-3000
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Fax | 909-509-5903
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 52133
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License Number State | CA
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