Provider Demographics
NPI:1548259799
Name:LUM, BRUCE (DMD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:
Last Name:LUM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:157 BEACH 145TH ST
Mailing Address - Street 2:
Mailing Address - City:NEPONSIT
Mailing Address - State:NY
Mailing Address - Zip Code:11694-1143
Mailing Address - Country:US
Mailing Address - Phone:718-996-7700
Mailing Address - Fax:718-996-8180
Practice Address - Street 1:3028 MERMAID AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11224-1806
Practice Address - Country:US
Practice Address - Phone:718-996-7700
Practice Address - Fax:718-996-8180
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-20
Last Update Date:2008-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0377411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00809518Medicaid