Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | D23636 | CA |
NPI | 1003968934 |
---|---|
Provider Name | Dr. Mark Steven Lisagor |
First Address | Camarillo, CA 93010-1812 |
Second Address | Camarillo, CA 93010-1482 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 18/01/2007 |
Last Update Date | 08/07/2007 |