Provider Demographics
NPI:1629450598
Name:LOURDES B. CAPULONG DDS INC
Entity Type:Organization
Organization Name:LOURDES B. CAPULONG DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LOURDES
Authorized Official - Middle Name:BUENO
Authorized Official - Last Name:CAPULONG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:323-257-7582
Mailing Address - Street 1:4409 EAGLE ROCK BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90041-3212
Mailing Address - Country:US
Mailing Address - Phone:323-257-7582
Mailing Address - Fax:323-257-2612
Practice Address - Street 1:4409 EAGLE ROCK BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90041-3212
Practice Address - Country:US
Practice Address - Phone:323-257-7582
Practice Address - Fax:323-257-2612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-26
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40551261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental