Healthcare Provider Details

I. General information

NPI: 1164472353
Provider Name (Legal Business Name): LAN SU DMD PHD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31332 VIA COLINAS SUITE 109
WESTLAKE VILLAGE CA
91362-3910
US

IV. Provider business mailing address

31332 VIA COLINAS SUITE 109
WESTLAKE VILLAGE CA
91362-3910
US

V. Phone/Fax

Practice location:
  • Phone: 818-865-1039
  • Fax: 818-865-8375
Mailing address:
  • Phone: 818-865-1039
  • Fax: 818-865-8375

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number46977
License Number StateCA

VIII. Authorized Official

Name: DR. LAN SU
Title or Position: OWNER DOCTOR
Credential: DMD, PHD
Phone: 818-865-1039