Healthcare Provider Details

I. General information

NPI: 1831530187
Provider Name (Legal Business Name): KHANH V LUONG DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2013
Last Update Date: 07/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40TH & HOLDREGE STREET ORTHODONTIC DEPARTMENT
LINCOLN NE
68583-0740
US

IV. Provider business mailing address

2911 FLETCHER AVE APT 126
LINCOLN NE
68504-1011
US

V. Phone/Fax

Practice location:
  • Phone: 337-296-1045
  • Fax:
Mailing address:
  • Phone: 337-296-1045
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number6363
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: