Provider Demographics
NPI:1740407451
Name:ANCHETA, MIA LARISSA (DDS)
Entity Type:Individual
Prefix:DR
First Name:MIA
Middle Name:LARISSA
Last Name:ANCHETA
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 1:3560 LEXINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:EL MONTE
Mailing Address - State:CA
Mailing Address - Zip Code:91731-2608
Mailing Address - Country:US
Mailing Address - Phone:626-448-9867
Mailing Address - Fax:626-448-2202
Practice Address - Street 1:3560 LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91731-2608
Practice Address - Country:US
Practice Address - Phone:626-448-9867
Practice Address - Fax:626-448-2202
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA478391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice