MEDICARE: DR. IMELDA LISA IGNACIO DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	48464	CA

General Provider Information

NPI Number	:	1215035688
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. IMELDA LISA IGNACIO DDS

Provider Business Mailing Address
First Line	:	1131 N VERMONT AVENUE
Second Line	:	SUITE 102
City	:	LOS ANGELES
State	:	CA
Zip	:	90029
Country	:	US
Telephone Number	:	323-661-6706
Fax Number	:	323-661-6078

Provider Business Practice Location Address
First Line	:	1131 N VERMONT AVENUE
Second Line	:	SUITE 102
City	:	LOS ANGELES
State	:	CA
Zip	:	90029
Country	:	US
Telephone Number	:	323-661-6706
Fax Number	:	323-661-6078

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	07/08/2007

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