Provider Demographics
NPI:1457399800
Name:LUNA, BRYAN A (DDS,MS)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:A
Last Name:LUNA
Suffix:
Gender:M
Credentials:DDS,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 N CABLE RD
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45805-2132
Mailing Address - Country:US
Mailing Address - Phone:419-331-0000
Mailing Address - Fax:419-331-5002
Practice Address - Street 1:505 N CABLE RD
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45805-2132
Practice Address - Country:US
Practice Address - Phone:419-331-0000
Practice Address - Fax:419-331-5002
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-04
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-0205431223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHT71057Medicare UPIN
OHLU0813681Medicare ID - Type UnspecifiedGROUP NUMBER