Healthcare Provider Details

I. General information

NPI: 1588078224
Provider Name (Legal Business Name): RICARDO LUGO DDS, MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2014
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411 E. 31ST ST E2 CLINIC - ORAL & MAXILLOFACIAL SURGERY
OAKLAND CA
94602-1018
US

IV. Provider business mailing address

1411 E. 31ST ST E2 CLINIC - ORAL & MAXILLOFACIAL SURGERY
OAKLAND CA
94602-1018
US

V. Phone/Fax

Practice location:
  • Phone: 510-437-4800
  • Fax:
Mailing address:
  • Phone: 510-437-4800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberA158305
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number63027
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: