Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0106X | Oral and Maxillofacial Pathology | 46977 | CA |
NPI | 1184869463 |
---|---|
Provider Name | Lan Su |
First Address | Westlake Village, CA 91362-6779 |
Second Address | Westlake Village, CA 91362-6779 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/12/2008 |
Last Update Date | 15/12/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U87454 | (02) | CA |