Provider Demographics
NPI:1275914863
Name:ALONZO, LISETTE OLIVIA (RDA)
Entity Type:Individual
Prefix:
First Name:LISETTE
Middle Name:OLIVIA
Last Name:ALONZO
Suffix:
Gender:F
Credentials:RDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7969 CLETA ST
Mailing Address - Street 2:
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90241-4793
Mailing Address - Country:US
Mailing Address - Phone:562-861-2746
Mailing Address - Fax:
Practice Address - Street 1:2604 S VERMONT AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90007-2298
Practice Address - Country:US
Practice Address - Phone:323-731-3333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-09
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA689557126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant