Provider Demographics
NPI:1104970383
Name:LUGTU, MICHAEL JERRY (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JERRY
Last Name:LUGTU
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16369 BROOKSTONE CIR
Mailing Address - Street 2:
Mailing Address - City:LA MIRADA
Mailing Address - State:CA
Mailing Address - Zip Code:90638-6531
Mailing Address - Country:US
Mailing Address - Phone:562-943-6898
Mailing Address - Fax:562-630-4690
Practice Address - Street 1:15122 PARAMOUNT BLVD
Practice Address - Street 2:
Practice Address - City:PARAMOUNT
Practice Address - State:CA
Practice Address - Zip Code:90723-4337
Practice Address - Country:US
Practice Address - Phone:562-630-2222
Practice Address - Fax:562-630-4690
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42851122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist