Provider Demographics
NPI:1508903121
Name:LU, HERMINIO MARCO (DDS)
Entity Type:Individual
Prefix:DR
First Name:HERMINIO
Middle Name:MARCO
Last Name:LU
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 PENNSYLVANIA AVE APT E6
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-6434
Mailing Address - Country:US
Mailing Address - Phone:707-685-2358
Mailing Address - Fax:707-427-8840
Practice Address - Street 1:1600 TRAVIS BLVD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-3429
Practice Address - Country:US
Practice Address - Phone:707-429-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49584122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist