1407079767 NPI number — DR. MADEL P LACSON DMD

Table of content: DR. MADEL P LACSON DMD (NPI 1407079767)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407079767 NPI number — DR. MADEL P LACSON DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LACSON
Provider First Name:
MADEL
Provider Middle Name:
P
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
F

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:
1407079767
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5211 E WASHINGTON BLVD
Provider Second Line Business Mailing Address:
SUITE #7
Provider Business Mailing Address City Name:
COMMERCE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90040-3960
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
323-267-0000
Provider Business Mailing Address Fax Number:
323-265-4442

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5211 E WASHINGTON BLVD
Provider Second Line Business Practice Location Address:
STE #7
Provider Business Practice Location Address City Name:
COMMERCE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90040-3960
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-267-0000
Provider Business Practice Location Address Fax Number:
323-265-4442
Provider Enumeration Date:
04/11/2007

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:  49353 , 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)

  • Identifier: B9407601 . This is a "MEDICAL DENTAL PROGRAM" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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