Provider Demographics
NPI:1447504212
Name:MABANSAG, LALAINE CALINOG (DDS)
Entity type:Individual
Prefix:
First Name:LALAINE
Middle Name:CALINOG
Last Name:MABANSAG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5120 CAHUENGA BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91601-4001
Mailing Address - Country:US
Mailing Address - Phone:818-427-3627
Mailing Address - Fax:
Practice Address - Street 1:9063 VAN NUYS BLVD
Practice Address - Street 2:
Practice Address - City:PANORAMA CITY
Practice Address - State:CA
Practice Address - Zip Code:91402-1812
Practice Address - Country:US
Practice Address - Phone:818-830-0212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-01
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA451431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice