Provider Demographics
NPI:1932331246
Name:MARTIN W. LAKSANA DDS INC
Entity Type:Organization
Organization Name:MARTIN W. LAKSANA DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:W
Authorized Official - Last Name:LAKSANA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:909-949-7002
Mailing Address - Street 1:130 S. MOUNTAIN AVE.
Mailing Address - Street 2:#G
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-6269
Mailing Address - Country:US
Mailing Address - Phone:909-949-7002
Mailing Address - Fax:
Practice Address - Street 1:130 S. MOUNTAIN AVE.
Practice Address - Street 2:#G
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-6269
Practice Address - Country:US
Practice Address - Phone:909-949-7002
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-20
Last Update Date:2009-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB355121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty