Provider Demographics
NPI:1912464033
Name:WILLIAMS, LARISA BREANA
Entity Type:Individual
Prefix:
First Name:LARISA
Middle Name:BREANA
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13808 CERISE AVE APT 14
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-8722
Mailing Address - Country:US
Mailing Address - Phone:310-469-8181
Mailing Address - Fax:
Practice Address - Street 1:13808 CERISE AVE APT 14
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-8722
Practice Address - Country:US
Practice Address - Phone:310-469-8181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-25
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDA89125126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant