1104955475 NPI number — LUCERO DENTAL CLINIC

Table of content: (NPI 1104955475)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104955475 NPI number — LUCERO DENTAL CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LUCERO DENTAL CLINIC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1104955475
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/08/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12833 HARBOR BLVD
Provider Second Line Business Mailing Address:
SUITE F 3
Provider Business Mailing Address City Name:
GARDEN GROVE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92840-5806
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-534-9480
Provider Business Mailing Address Fax Number:
714-534-9482

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12833 HARBOR BLVD
Provider Second Line Business Practice Location Address:
SUITE F 3
Provider Business Practice Location Address City Name:
GARDEN GROVE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92840-5806
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-534-9480
Provider Business Practice Location Address Fax Number:
714-534-9482
Provider Enumeration Date:
03/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LUCERO
Authorized Official First Name:
MARTHA
Authorized Official Middle Name:
R
Authorized Official Title or Position:
OWNER AND PRESIDENT
Authorized Official Telephone Number:
714-534-9480

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  35947 , 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)





Copyright © 2007-2025 www.npivalidator.com