Healthcare Provider Details

I. General information

NPI: 1568516573
Provider Name (Legal Business Name): JENNIFER YONG LUNA D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 04/22/2020
Certification Date: 04/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22725 44TH AVE W STE 100
MOUNTLAKE TERRACE WA
98043-4583
US

IV. Provider business mailing address

22725 44TH AVE W STE 100
MOUNTLAKE TERRACE WA
98043-4583
US

V. Phone/Fax

Practice location:
  • Phone: 425-412-3955
  • Fax: 425-967-5583
Mailing address:
  • Phone: 425-412-3955
  • Fax: 425-967-5583

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE00009278
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDE00009278
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: