Provider Demographics
NPI:1699381285
Name:BUBALO, LANA (DDS)
Entity Type:Individual
Prefix:DR
First Name:LANA
Middle Name:
Last Name:BUBALO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5359 LA JOLLA BLVD UNIT 24
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-7955
Mailing Address - Country:US
Mailing Address - Phone:408-489-8076
Mailing Address - Fax:
Practice Address - Street 1:8430 LEMON AVE
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91941-5310
Practice Address - Country:US
Practice Address - Phone:619-466-8363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-18
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA105502122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist