Provider Demographics
NPI:1053604637
Name:LUPISAN, NORBERTO BRAVO (DDS)
Entity type:Individual
Prefix:DR
First Name:NORBERTO
Middle Name:BRAVO
Last Name:LUPISAN
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:PO BOX 12113
Mailing Address - Street 2:
Mailing Address - City:LA CRESCENTA
Mailing Address - State:CA
Mailing Address - Zip Code:91224-0813
Mailing Address - Country:US
Mailing Address - Phone:818-248-7126
Mailing Address - Fax:
Practice Address - Street 1:1131 N VERMONT AVE
Practice Address - Street 2:STE. 103
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90029-1764
Practice Address - Country:US
Practice Address - Phone:323-913-1352
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-16
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60135122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist