Provider Demographics
NPI:1477643898
Name:LUAT, CHARISMA (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARISMA
Middle Name:
Last Name:LUAT
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:MIA
Other - Middle Name:
Other - Last Name:TOY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:3524 W IRVING PARK RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-3210
Mailing Address - Country:US
Mailing Address - Phone:773-588-4650
Mailing Address - Fax:773-588-4631
Practice Address - Street 1:3524 W IRVING PARK RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-3210
Practice Address - Country:US
Practice Address - Phone:773-588-4650
Practice Address - Fax:773-588-4631
Is Sole Proprietor?:No
Enumeration Date:2006-10-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1447265970Medicaid