Provider Demographics
NPI:1265767719
Name:LUKMAN, ERICK SURYADI (DMD)
Entity type:Individual
Prefix:
First Name:ERICK
Middle Name:SURYADI
Last Name:LUKMAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1124 EDDY ST UNIT A
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94109-7669
Mailing Address - Country:US
Mailing Address - Phone:858-232-2089
Mailing Address - Fax:
Practice Address - Street 1:2480 MISSION ST STE 325
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-2463
Practice Address - Country:US
Practice Address - Phone:415-285-7700
Practice Address - Fax:415-285-7755
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-15
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA587581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice