Provider Demographics
NPI:1780901306
Name:DEPETRILLO, LIZA (DMD)
Entity type:Individual
Prefix:DR
First Name:LIZA
Middle Name:
Last Name:DEPETRILLO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:LIZA
Other - Middle Name:
Other - Last Name:DEPETRILLO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:4165 BLACKHAWK PLAZA CIR
Mailing Address - Street 2:#200
Mailing Address - City:DANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94506-4904
Mailing Address - Country:US
Mailing Address - Phone:925-736-4201
Mailing Address - Fax:
Practice Address - Street 1:4165 BLACKHAWK PLAZA CIR STE 200
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:CA
Practice Address - Zip Code:94506-4691
Practice Address - Country:US
Practice Address - Phone:925-736-4201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-21
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD565601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice