Provider Demographics
NPI:1255773032
Name:LIRA, LEAH RETANIA (RDA)
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:RETANIA
Last Name:LIRA
Suffix:
Gender:F
Credentials:RDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 W CYPRESS ST
Mailing Address - Street 2:APT 6
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-2637
Mailing Address - Country:US
Mailing Address - Phone:213-448-5311
Mailing Address - Fax:
Practice Address - Street 1:126 W CYPRESS ST
Practice Address - Street 2:APT 6
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2637
Practice Address - Country:US
Practice Address - Phone:213-448-5311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-22
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA71380126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant