Basic Information
| Provider Information | |||||||||
| NPI: | 1982107868 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LA NOIRE | ||||||||
| FirstName: | BORIS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4870 GENEVA AVE | ||||||||
| Address2: | |||||||||
| City: | CONCORD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945212227 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 9130 ALCOSTA BLVD STE A | ||||||||
| Address2: | |||||||||
| City: | SAN RAMON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945833847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9252309414 | ||||||||
| FaxNumber: | 9258032568 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2018 | ||||||||
| LastUpdateDate: | 04/30/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223D0001X | 102327 | CA | N | Dental Providers | Dentist | Dental Public Health | 122300000X | 102327 | CA | Y | Dental Providers | Dentist |
No ID Information.