Provider Demographics
NPI:1639185929
Name:LUU, THANH TAN (DDS)
Entity Type:Individual
Prefix:MR
First Name:THANH
Middle Name:TAN
Last Name:LUU
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 1:8647 ELK GROVE BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95624
Mailing Address - Country:US
Mailing Address - Phone:916-714-0702
Mailing Address - Fax:916-714-0704
Practice Address - Street 1:8647 ELK GROVE BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95624
Practice Address - Country:US
Practice Address - Phone:916-714-0702
Practice Address - Fax:916-714-0704
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46292122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG92397-01Medicaid