Provider Demographics
NPI:1063533024
Name:LU, POONAM (DDS)
Entity type:Individual
Prefix:DR
First Name:POONAM
Middle Name:
Last Name:LU
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 PORTER AVE
Mailing Address - Street 2:SUITE I
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-4297
Mailing Address - Country:US
Mailing Address - Phone:209-956-6116
Mailing Address - Fax:209-956-2877
Practice Address - Street 1:702 PORTER AVE
Practice Address - Street 2:SUITE I
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-4297
Practice Address - Country:US
Practice Address - Phone:209-956-6116
Practice Address - Fax:209-956-2877
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA469321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG-98303-01 HFPOtherHEALTHY FAMILIES HFP