Provider Demographics
NPI:1114678117
Name:CASTRO, LUSHANA MARIE (RDH)
Entity Type:Individual
Prefix:MS
First Name:LUSHANA
Middle Name:MARIE
Last Name:CASTRO
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3145 GARDEN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78234-7718
Mailing Address - Country:US
Mailing Address - Phone:210-808-3735
Mailing Address - Fax:
Practice Address - Street 1:3145 GARDEN AVE
Practice Address - Street 2:
Practice Address - City:JBSA FT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-7718
Practice Address - Country:US
Practice Address - Phone:210-808-3735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-12
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17911124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist