Provider Demographics
NPI:1013367259
Name:PLAYA VISTA DENTAL
Entity Type:Organization
Organization Name:PLAYA VISTA DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:FUNG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:213-453-3407
Mailing Address - Street 1:12975 AGUSTIN PL
Mailing Address - Street 2:#125
Mailing Address - City:PLAYA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:90094-2307
Mailing Address - Country:US
Mailing Address - Phone:213-453-3407
Mailing Address - Fax:
Practice Address - Street 1:12975 AGUSTIN PL
Practice Address - Street 2:#125
Practice Address - City:PLAYA VISTA
Practice Address - State:CA
Practice Address - Zip Code:90094-2307
Practice Address - Country:US
Practice Address - Phone:213-453-3407
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-19
Last Update Date:2016-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA607531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty