Provider Demographics
NPI:1467863647
Name:NARISSA AMBATA DDS INC
Entity type:Organization
Organization Name:NARISSA AMBATA DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NARISSA
Authorized Official - Middle Name:BAWALAN
Authorized Official - Last Name:AMBATA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:323-560-8999
Mailing Address - Street 1:4509 SLAUSON AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:MAYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90270-2954
Mailing Address - Country:US
Mailing Address - Phone:323-560-8999
Mailing Address - Fax:
Practice Address - Street 1:4509 SLAUSON AVE
Practice Address - Street 2:SUITE B
Practice Address - City:MAYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90270-2954
Practice Address - Country:US
Practice Address - Phone:323-560-8999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-09
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA61070122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty