Healthcare Provider Details

I. General information

NPI: 1649323007
Provider Name (Legal Business Name): JIANWEI JENNY LU D. D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JENNY LU DDS

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 11/09/2023
Certification Date: 11/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1282 NW CIVIC DR
GRESHAM OR
97030-5509
US

IV. Provider business mailing address

1282 NW CIVIC DR
GRESHAM OR
97030-5509
US

V. Phone/Fax

Practice location:
  • Phone: 503-760-1334
  • Fax: 503-762-1955
Mailing address:
  • Phone: 503-760-1334
  • Fax: 503-762-1955

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7739
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: