Healthcare Provider Details

I. General information

NPI: 1356255863
Provider Name (Legal Business Name): CERJAY LUGTU
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2026
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16369 BROOKSTONE CIR
LA MIRADA CA
90638-6531
US

IV. Provider business mailing address

16369 BROOKSTONE CIR
LA MIRADA CA
90638-6531
US

V. Phone/Fax

Practice location:
  • Phone: 562-458-9757
  • Fax:
Mailing address:
  • Phone: 562-458-9757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number113772
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: