Provider Demographics
NPI:1346728664
Name:JIM LU AND SHANE LU DDS PLLC
Entity Type:Organization
Organization Name:JIM LU AND SHANE LU DDS PLLC
Other - Org Name:BURLINGTON DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:LU
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:706-254-4191
Mailing Address - Street 1:322 S DAVIE ST APT 208
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-2856
Mailing Address - Country:US
Mailing Address - Phone:706-254-4191
Mailing Address - Fax:
Practice Address - Street 1:2430 S CHURCH ST STE B
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215
Practice Address - Country:US
Practice Address - Phone:336-639-7101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-30
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103191223G0001X
NC99691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1922486703Medicaid
NC1952719353Medicaid