Provider Demographics
NPI:1225248982
Name:SIA SU, MARY JUDY LO (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARY JUDY
Middle Name:LO
Last Name:SIA SU
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 E LAS TUNAS DR
Mailing Address - Street 2:SUITE #10
Mailing Address - City:SAN GABRIEL
Mailing Address - State:CA
Mailing Address - Zip Code:91776-1411
Mailing Address - Country:US
Mailing Address - Phone:626-285-0337
Mailing Address - Fax:626-285-0486
Practice Address - Street 1:206 E LAS TUNAS DR
Practice Address - Street 2:SUITE #10
Practice Address - City:SAN GABRIEL
Practice Address - State:CA
Practice Address - Zip Code:91776-1411
Practice Address - Country:US
Practice Address - Phone:626-285-0337
Practice Address - Fax:626-285-0486
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA415501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice