Provider Demographics
NPI:1891860912
Name:YAOWARATTANA, LALISA (DDS)
Entity Type:Individual
Prefix:
First Name:LALISA
Middle Name:
Last Name:YAOWARATTANA
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 1:22737 BARTON RD STE 12
Mailing Address - Street 2:
Mailing Address - City:GRAND TERRACE
Mailing Address - State:CA
Mailing Address - Zip Code:92313-5201
Mailing Address - Country:US
Mailing Address - Phone:909-825-3000
Mailing Address - Fax:909-509-5903
Practice Address - Street 1:22737 BARTON RD STE 12
Practice Address - Street 2:
Practice Address - City:GRAND TERRACE
Practice Address - State:CA
Practice Address - Zip Code:92313-5201
Practice Address - Country:US
Practice Address - Phone:909-825-3000
Practice Address - Fax:909-509-5903
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52133122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist