Provider Demographics
NPI:1063025245
Name:LUX DENTAL CENTER
Entity Type:Organization
Organization Name:LUX DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ABDULLAIBRAHIM
Authorized Official - Middle Name:
Authorized Official - Last Name:ABDULWAHEED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-639-5942
Mailing Address - Street 1:181 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02143-3137
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:181 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02143-3137
Practice Address - Country:US
Practice Address - Phone:617-639-5942
Practice Address - Fax:888-832-8267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-26
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1851932198Medicaid
MA1861878712Medicaid
MA1053710400Medicaid
MA1083029102Medicaid
MA1235752189Medicaid
MA1427424332Medicaid
MA1760576250Medicaid
MA1790121259Medicaid
MA1801220009Medicaid
MA1922668961Medicaid
MA1275916116Medicaid
MA1699143917Medicaid
MA1578939351Medicaid
MA1619347788Medicaid
MA1891251559Medicaid