Provider Demographics
NPI:1689167041
Name:LUU, ELLEN THAO (DMD)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:THAO
Last Name:LUU
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9702 BOLSA AVE SPC 10
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92683-6620
Mailing Address - Country:US
Mailing Address - Phone:714-260-7190
Mailing Address - Fax:
Practice Address - Street 1:19720 BEACH BLVD STE A
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92648-3506
Practice Address - Country:US
Practice Address - Phone:714-260-7190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-11
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX34040122300000X
CA103681122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist