Healthcare Provider Details

I. General information

NPI: 1164378055
Provider Name (Legal Business Name): DR. JACKY LUNG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2026
Last Update Date: 03/05/2026
Certification Date: 03/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1439 S SAINT FRANCIS DR
SANTA FE NM
87505-4037
US

IV. Provider business mailing address

955 RICHARDS AVE APT 1016
SANTA FE NM
87507-6213
US

V. Phone/Fax

Practice location:
  • Phone: 505-473-5437
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDB-2025-0259
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: