Provider Demographics
NPI:1750558060
Name:JUANA E LUSTER DDS PC
Entity type:Organization
Organization Name:JUANA E LUSTER DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JUANA
Authorized Official - Middle Name:E
Authorized Official - Last Name:LUSTER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-339-3358
Mailing Address - Street 1:1376 EAST 15 ST
Mailing Address - Street 2:
Mailing Address - City:BKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230
Mailing Address - Country:US
Mailing Address - Phone:718-339-3358
Mailing Address - Fax:718-339-3358
Practice Address - Street 1:1376 EAST 15 ST
Practice Address - Street 2:
Practice Address - City:BKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230
Practice Address - Country:US
Practice Address - Phone:718-339-3358
Practice Address - Fax:718-339-3358
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JUANA E LUSTER DDS PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-15
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY04620511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01668482Medicaid