Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | 58149 | CA |
NPI | 1083947121 |
---|---|
Provider Name | Dr. Theresia Laksmana |
First Address | Los Angeles, CA 90089-0641 |
Second Address | Los Angeles, CA 90089-0641 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/09/2009 |
Last Update Date | 12/08/2011 |