Provider Demographics
NPI:1285885137
Name:LUM, JACLYN M (DDS)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:M
Last Name:LUM
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 1:1109 YOUNG ST
Mailing Address - Street 2:STE 106
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96814-1990
Mailing Address - Country:US
Mailing Address - Phone:808-591-0086
Mailing Address - Fax:
Practice Address - Street 1:1109 YOUNG ST
Practice Address - Street 2:STE 106
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-1990
Practice Address - Country:US
Practice Address - Phone:808-591-0086
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-08
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDT 23581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice