Provider Demographics
NPI:1982278115
Name:LUO, LEWIS WENBUO YIN
Entity Type:Individual
Prefix:
First Name:LEWIS
Middle Name:WENBUO YIN
Last Name:LUO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22180 LATHAM DR
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:VA
Mailing Address - Zip Code:24202-4940
Mailing Address - Country:US
Mailing Address - Phone:206-724-8158
Mailing Address - Fax:
Practice Address - Street 1:616 CAMPUS DR STE 100
Practice Address - Street 2:
Practice Address - City:ABINGDON
Practice Address - State:VA
Practice Address - Zip Code:24210-9706
Practice Address - Country:US
Practice Address - Phone:276-525-4487
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-13
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60966563122300000X
VA0401418018122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist