Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223D0001X | Dental Public Health | 61596 | CA |
NPI | 1487904215 |
---|---|
Provider Name | Brian Thomas Lu |
First Address | Fort Defiance, AZ 86504-0649 |
Second Address | Fort Defiance, AZ 86504-0649 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 19/09/2012 |
Last Update Date | 05/06/2013 |