Provider Demographics
NPI:1275874794
Name:LAMPA, LIEZL (DDS, MPH)
Entity Type:Individual
Prefix:
First Name:LIEZL
Middle Name:
Last Name:LAMPA
Suffix:
Gender:F
Credentials:DDS, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:676 SHADY PL
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-4608
Mailing Address - Country:US
Mailing Address - Phone:951-264-7865
Mailing Address - Fax:
Practice Address - Street 1:2020 CORTELYOU ROAD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11226
Practice Address - Country:US
Practice Address - Phone:951-264-7865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-07
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY057381122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04000928Medicaid