Provider Demographics
NPI:1316281090
Name:MONCAYO, CERISA (DDS)
Entity type:Individual
Prefix:
First Name:CERISA
Middle Name:
Last Name:MONCAYO
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 1:881 ALMA REAL DR STE T2
Mailing Address - Street 2:APT. 701
Mailing Address - City:PACIFIC PALISADES
Mailing Address - State:CA
Mailing Address - Zip Code:90272-3741
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:881 ALMA REAL DR STE T2
Practice Address - Street 2:APT. 701
Practice Address - City:PACIFIC PALISADES
Practice Address - State:CA
Practice Address - Zip Code:90272-3741
Practice Address - Country:US
Practice Address - Phone:310-459-2302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-19
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA61688122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist