Provider Demographics
NPI:1275517518
Name:CAPULONG, LOURDES BUENO (DDS)
Entity Type:Individual
Prefix:DR
First Name:LOURDES
Middle Name:BUENO
Last Name:CAPULONG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4409 EAGLE ROCK BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90041-3212
Mailing Address - Country:US
Mailing Address - Phone:323-257-7582
Mailing Address - Fax:323-257-2612
Practice Address - Street 1:4409 EAGLE ROCK BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90041-3212
Practice Address - Country:US
Practice Address - Phone:323-257-7582
Practice Address - Fax:323-257-2612
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA405511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice