1053604637 NPI number — DR. NORBERTO BRAVO LUPISAN DDS

Table of content: DR. NORBERTO BRAVO LUPISAN DDS (NPI 1053604637)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053604637 NPI number — DR. NORBERTO BRAVO LUPISAN DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LUPISAN
Provider First Name:
NORBERTO
Provider Middle Name:
BRAVO
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053604637
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/22/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 12113
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LA CRESCENTA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91224-0813
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-248-7126
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1131 N VERMONT AVE
Provider Second Line Business Practice Location Address:
STE. 103
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90029-1764
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-913-1352
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/16/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  60135 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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