Provider Demographics
NPI:1609986686
Name:LU, PHONG (DDS)
Entity Type:Individual
Prefix:DR
First Name:PHONG
Middle Name:
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 1:1000 VALE TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92084-5218
Mailing Address - Country:US
Mailing Address - Phone:760-631-5000
Mailing Address - Fax:
Practice Address - Street 1:420 S GLENDORA AVE
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-3001
Practice Address - Country:US
Practice Address - Phone:626-919-5724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA475181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice