Healthcare Provider Details

I. General information

NPI: 1619103546
Provider Name (Legal Business Name): MICHAEL GARY LUM DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2009
Last Update Date: 06/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12264 EL CAMINO REAL SUITE 306
SAN DIEGO CA
92130-3058
US

IV. Provider business mailing address

12264 EL CAMINO REAL SUITE 306
SAN DIEGO CA
92130-3058
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number53922
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: