Provider Demographics
NPI:1972175743
Name:PETROSSPOUR, LARISSA MARY (DDS)
Entity type:Individual
Prefix:DR
First Name:LARISSA
Middle Name:MARY
Last Name:PETROSSPOUR
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 1:4440 E VILLAGE RD
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90808-1540
Mailing Address - Country:US
Mailing Address - Phone:562-425-3311
Mailing Address - Fax:
Practice Address - Street 1:4440 E VILLAGE RD
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90808-1540
Practice Address - Country:US
Practice Address - Phone:562-425-3311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-12
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS106422122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist