Provider Demographics
NPI:1477858868
Name:GIANCARLO A. LAURIENTE, DDS, INC.
Entity Type:Organization
Organization Name:GIANCARLO A. LAURIENTE, DDS, INC.
Other - Org Name:FIVE CITIES PEDIATRIC DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:GIANCARLO
Authorized Official - Middle Name:
Authorized Official - Last Name:LAURIENTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-773-1600
Mailing Address - Street 1:2 JAMES WAY
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93449-4973
Mailing Address - Country:US
Mailing Address - Phone:805-773-1600
Mailing Address - Fax:
Practice Address - Street 1:2 JAMES WAY
Practice Address - Street 2:SUITE 201
Practice Address - City:PISMO BEACH
Practice Address - State:CA
Practice Address - Zip Code:93449-4973
Practice Address - Country:US
Practice Address - Phone:805-773-1600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-17
Last Update Date:2012-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA551441223P0221X
CA579561223P0221X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty