Basic Information
| Provider Information | |||||||||
| NPI: | 1003454489 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LUI | ||||||||
| FirstName: | EMMELINE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RDH | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherCredential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3110 KERNER BLVD STE B | ||||||||
| Address2: | |||||||||
| City: | SAN RAFAEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949015411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4154481500 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3110 KERNER BLVD | ||||||||
| Address2: | |||||||||
| City: | SAN RAFAEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949015411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4154481500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2019 | ||||||||
| LastUpdateDate: | 02/16/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | 02/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | 30679 | CA | Y | Dental Providers | Dental Hygienist |
ID Information
| ID | Type | State | Issuer | Description | 30679 | 01 | CA | DENTAL HYGIENE BOARD OF CALIFORNIA | OTHER |