Healthcare Provider Details

I. General information

NPI: 1255634903
Provider Name (Legal Business Name): LUSTIG AND YOUNG DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2010
Last Update Date: 09/17/2024
Certification Date: 09/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13297 JAMBOREE RD
TUSTIN CA
92782-9159
US

IV. Provider business mailing address

13297 JAMBOREE RD
TUSTIN CA
92782-9159
US

V. Phone/Fax

Practice location:
  • Phone: 714-730-6600
  • Fax: 951-776-1571
Mailing address:
  • Phone: 714-730-6600
  • Fax: 714-730-6082

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number44088
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ANDREW YOUNG
Title or Position: OWNER
Credential: DDS, MS
Phone: 714-730-6600