Provider Demographics
NPI:1124296884
Name:LARA, FABIOLA A (DDS)
Entity type:Individual
Prefix:DR
First Name:FABIOLA
Middle Name:A
Last Name:LARA
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 1:450 SUTTER ST
Mailing Address - Street 2:#1620
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94108-4206
Mailing Address - Country:US
Mailing Address - Phone:415-986-4556
Mailing Address - Fax:415-986-4610
Practice Address - Street 1:450 SUTTER ST
Practice Address - Street 2:#1620
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94108-4206
Practice Address - Country:US
Practice Address - Phone:415-986-4556
Practice Address - Fax:415-986-4610
Is Sole Proprietor?:No
Enumeration Date:2008-02-15
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA566541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice