Provider Demographics
NPI:1063896587
Name:SIU, LAURITA (DDS, MPH)
Entity type:Individual
Prefix:
First Name:LAURITA
Middle Name:
Last Name:SIU
Suffix:
Gender:F
Credentials:DDS, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12821 MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92345
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1001 SHADOW LN
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4124
Practice Address - Country:US
Practice Address - Phone:702-774-2416
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-14
Last Update Date:2017-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1013801223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry