Provider Demographics
NPI:1982107868
Name:LA NOIRE, BORIS
Entity Type:Individual
Prefix:
First Name:BORIS
Middle Name:
Last Name:LA NOIRE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4870 GENEVA AVE
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94521-2227
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9130 ALCOSTA BLVD STE A
Practice Address - Street 2:
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-3847
Practice Address - Country:US
Practice Address - Phone:925-230-9414
Practice Address - Fax:925-803-2568
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-16
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1023271223D0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223D0001XDental ProvidersDentistDental Public Health