Healthcare Provider Details

I. General information

NPI: 1386371607
Provider Name (Legal Business Name): LU TRAN DDS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2022
Last Update Date: 08/05/2022
Certification Date: 08/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 SUDDERTH DR STE C
RUIDOSO NM
88345-6001
US

IV. Provider business mailing address

200 SUDDERTH DR STE C
RUIDOSO NM
88345-6001
US

V. Phone/Fax

Practice location:
  • Phone: 575-315-2996
  • Fax:
Mailing address:
  • Phone: 575-315-2996
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State

VIII. Authorized Official

Name: BRIAN LU
Title or Position: DENTIST
Credential: DDS
Phone: 575-315-2996