Provider Demographics
NPI:1619189255
Name:LASSITER, LONNIE BOB (DDS)
Entity Type:Individual
Prefix:
First Name:LONNIE
Middle Name:BOB
Last Name:LASSITER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:862 MEINECKE AVE
Mailing Address - Street 2:#200
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405-1721
Mailing Address - Country:US
Mailing Address - Phone:805-544-7804
Mailing Address - Fax:805-544-6020
Practice Address - Street 1:862 MEINECKE AVE
Practice Address - Street 2:#200
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-1721
Practice Address - Country:US
Practice Address - Phone:805-544-7804
Practice Address - Fax:805-544-6020
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA268791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice