Provider Demographics
NPI:1356897235
Name:WANG, LU
Entity type:Individual
Prefix:
First Name:LU
Middle Name:
Last Name:WANG
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:MCAS MIRAMAR DENTAL CLINIC
Mailing Address - Street 2:7224 MITSCHER WAY
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92145
Mailing Address - Country:US
Mailing Address - Phone:858-307-1825
Mailing Address - Fax:
Practice Address - Street 1:MCAS MIRAMAR DENTAL CLINIC
Practice Address - Street 2:7224 MITSCHER WAY
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92145-0000
Practice Address - Country:US
Practice Address - Phone:588-307-1825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-30
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD16004122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist