Provider Demographics
NPI:1164472353
Name:LAN SU DMD PHD
Entity Type:Organization
Organization Name:LAN SU DMD PHD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SU
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, PHD
Authorized Official - Phone:818-865-1039
Mailing Address - Street 1:31332 VIA COLINAS
Mailing Address - Street 2:SUITE 109
Mailing Address - City:WESTLAKE VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91362-3910
Mailing Address - Country:US
Mailing Address - Phone:818-865-1039
Mailing Address - Fax:818-865-8375
Practice Address - Street 1:31332 VIA COLINAS
Practice Address - Street 2:SUITE 109
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91362-3910
Practice Address - Country:US
Practice Address - Phone:818-865-1039
Practice Address - Fax:818-865-8375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA469771223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
D46977AMedicare ID - Type UnspecifiedPROVIDER ID
CAW19718Medicare ID - Type UnspecifiedGROUP ID
CAU87454Medicare UPIN
CAWD46977AMedicare ID - Type Unspecified