Provider Demographics
NPI:1134653256
Name:CERISA MONCAYO D.D.S. DENTAL CORPORATION
Entity Type:Organization
Organization Name:CERISA MONCAYO D.D.S. DENTAL CORPORATION
Other - Org Name:THE PALISADES DENTISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CERISA
Authorized Official - Middle Name:
Authorized Official - Last Name:MONCAYO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:661-902-1153
Mailing Address - Street 1:881 ALMA REAL DR STE T2
Mailing Address - Street 2:
Mailing Address - City:PACIFIC PALISADES
Mailing Address - State:CA
Mailing Address - Zip Code:90272-3741
Mailing Address - Country:US
Mailing Address - Phone:310-459-2303
Mailing Address - Fax:
Practice Address - Street 1:881 ALMA REAL DR STE T2
Practice Address - Street 2:
Practice Address - City:PACIFIC PALISADES
Practice Address - State:CA
Practice Address - Zip Code:90272-3741
Practice Address - Country:US
Practice Address - Phone:310-459-2303
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-14
Last Update Date:2017-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA61688122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty