Provider Demographics
NPI:1790276616
Name:LALA, MARUFA FAROOQUE
Entity type:Individual
Prefix:
First Name:MARUFA
Middle Name:FAROOQUE
Last Name:LALA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:MARUFA
Other - Middle Name:FAROOQUE
Other - Last Name:LALA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:20500 W SHELLEY LN
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91326-4965
Mailing Address - Country:US
Mailing Address - Phone:248-880-7352
Mailing Address - Fax:
Practice Address - Street 1:11568 VIKING AVE
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91326-1815
Practice Address - Country:US
Practice Address - Phone:248-880-7352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-25
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1024511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice