Provider Demographics
NPI:1265266134
Name:LUNA, LISA MARIE
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:LUNA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16142 BANBRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:LA PUENTE
Mailing Address - State:CA
Mailing Address - Zip Code:91744-4501
Mailing Address - Country:US
Mailing Address - Phone:626-225-5919
Mailing Address - Fax:
Practice Address - Street 1:8527 SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:NORTH HILLS
Practice Address - State:CA
Practice Address - Zip Code:91343-5824
Practice Address - Country:US
Practice Address - Phone:818-895-3100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-31
Last Update Date:2024-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36869124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist