Provider Demographics
NPI:1487904215
Name:LU, BRIAN THOMAS (DDS)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:THOMAS
Last Name:LU
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 1:200 SUDDERTH DR STE C
Mailing Address - Street 2:
Mailing Address - City:RUIDOSO
Mailing Address - State:NM
Mailing Address - Zip Code:88345-6001
Mailing Address - Country:US
Mailing Address - Phone:575-258-4698
Mailing Address - Fax:
Practice Address - Street 1:200 SUDDERTH DR STE C
Practice Address - Street 2:
Practice Address - City:RUIDOSO
Practice Address - State:NM
Practice Address - Zip Code:88345-6001
Practice Address - Country:US
Practice Address - Phone:575-258-4698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-19
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD55231223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty