Provider Demographics
NPI:1376116673
Name:LIM, LUANA JI HEE
Entity Type:Individual
Prefix:
First Name:LUANA
Middle Name:JI HEE
Last Name:LIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2613 S ERIN WAY
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-4181
Mailing Address - Country:US
Mailing Address - Phone:818-455-9106
Mailing Address - Fax:
Practice Address - Street 1:6331 HAVEN AVE STE 12
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91737-6942
Practice Address - Country:US
Practice Address - Phone:909-989-7222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-23
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1042871223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry