Provider Demographics
NPI:1255548871
Name:LISA B TABORA DDS INC
Entity type:Organization
Organization Name:LISA B TABORA DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIE LOUISE
Authorized Official - Middle Name:B
Authorized Official - Last Name:TABORA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:818-956-6101
Mailing Address - Street 1:710 E COLORADO ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-1712
Mailing Address - Country:US
Mailing Address - Phone:818-956-6101
Mailing Address - Fax:818-956-6156
Practice Address - Street 1:710 E COLORADO ST
Practice Address - Street 2:SUITE A
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-1712
Practice Address - Country:US
Practice Address - Phone:818-956-6101
Practice Address - Fax:818-956-6156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA424291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB42429OtherMEDICAL