Healthcare Provider Details

I. General information

NPI: 1134785058
Provider Name (Legal Business Name): ANDREW LUM DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2019
Last Update Date: 08/11/2022
Certification Date: 08/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12264 EL CAMINO REAL STE 306
SAN DIEGO CA
92130-3062
US

IV. Provider business mailing address

12264 EL CAMINO REAL STE 306
SAN DIEGO CA
92130-3062
US

V. Phone/Fax

Practice location:
  • Phone: 858-755-9810
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number103908
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: