Provider Demographics
NPI:1700191202
Name:WU, LISA G (DDS)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:G
Last Name:WU
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 1:13631 NIMES CT
Mailing Address - Street 2:
Mailing Address - City:CHINO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91709-1382
Mailing Address - Country:US
Mailing Address - Phone:909-548-2289
Mailing Address - Fax:
Practice Address - Street 1:3698 S BRISTOL ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92704-7302
Practice Address - Country:US
Practice Address - Phone:714-942-2447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-10
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND141121223S0112X
CA25146124Q00000X
CA64929122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No124Q00000XDental ProvidersDental Hygienist