Provider Demographics
NPI:1144948696
Name:LU, PHAT
Entity type:Individual
Prefix:
First Name:PHAT
Middle Name:
Last Name:LU
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 1:1000 VALE TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92084-5218
Mailing Address - Country:US
Mailing Address - Phone:760-631-5000
Mailing Address - Fax:
Practice Address - Street 1:1000 VALE TERRACE DR
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92084-5218
Practice Address - Country:US
Practice Address - Phone:844-308-5003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-19
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27531124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist