Healthcare Provider Details

I. General information

NPI: 1700191202
Provider Name (Legal Business Name): LISA G WU D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2010
Last Update Date: 06/12/2024
Certification Date: 06/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57950 LEAVENWORTH ST BLDG 250
MCCONNELL AFB KS
67221-3505
US

IV. Provider business mailing address

13631 NIMES CT
CHINO HILLS CA
91709-1382
US

V. Phone/Fax

Practice location:
  • Phone: 316-759-6300
  • Fax:
Mailing address:
  • Phone: 909-548-2289
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number25146
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number64929
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD14112
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: