Provider Demographics
NPI:1467443010
Name:VANTASSELL, ELIZABETH ANN (DDS)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:ANN
Last Name:VANTASSELL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:MISS
Other - First Name:ELIZABETH
Other - Middle Name:ANN
Other - Last Name:LAPTHORNE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:135 KELLER ST
Mailing Address - Street 2:STE F
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-2943
Mailing Address - Country:US
Mailing Address - Phone:707-778-6006
Mailing Address - Fax:707-778-1672
Practice Address - Street 1:135 KELLER ST
Practice Address - Street 2:STE F
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-2943
Practice Address - Country:US
Practice Address - Phone:707-778-6006
Practice Address - Fax:707-778-1672
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA 37765122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist