Provider Demographics
NPI:1518304062
Name:LUA, MARY L (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:L
Last Name:LUA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 S GLENDORA AVE
Mailing Address - Street 2:SUITE # A
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-4967
Mailing Address - Country:US
Mailing Address - Phone:626-813-3699
Mailing Address - Fax:
Practice Address - Street 1:1101 S GLENDORA AVE
Practice Address - Street 2:SUITE # A
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-4967
Practice Address - Country:US
Practice Address - Phone:626-813-3699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-23
Last Update Date:2013-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35136122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist