Provider Demographics
NPI:1972611689
Name:FEALY, LAWRENCE E (DDS)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:E
Last Name:FEALY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25880 TOURNAMENT RD
Mailing Address - Street 2:101
Mailing Address - City:VALENCIA
Mailing Address - State:CA
Mailing Address - Zip Code:91355-2349
Mailing Address - Country:US
Mailing Address - Phone:661-253-0812
Mailing Address - Fax:661-253-0239
Practice Address - Street 1:25880 TOURNAMENT RD
Practice Address - Street 2:SUITE 101
Practice Address - City:VALENCIA
Practice Address - State:CA
Practice Address - Zip Code:91355-2349
Practice Address - Country:US
Practice Address - Phone:661-253-0812
Practice Address - Fax:661-253-0239
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA349551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA527805OtherUNITED CONCORDIA ID#