Provider Demographics
NPI:1912188814
Name:LIWANAG, ELENITA B (DMD)
Entity Type:Individual
Prefix:DR
First Name:ELENITA
Middle Name:B
Last Name:LIWANAG
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:144 W CARSON ST
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90745-2601
Mailing Address - Country:US
Mailing Address - Phone:310-835-4088
Mailing Address - Fax:310-835-8488
Practice Address - Street 1:144 W CARSON ST
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90745-2601
Practice Address - Country:US
Practice Address - Phone:310-835-4088
Practice Address - Fax:310-835-8488
Is Sole Proprietor?:No
Enumeration Date:2007-11-19
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38963122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1790798684OtherNPI CORPORATE