Provider Demographics
NPI:1114124104
Name:SAMUEL, LOLADE T (DDS)
Entity Type:Individual
Prefix:DR
First Name:LOLADE
Middle Name:T
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:LOLADE
Other - Middle Name:
Other - Last Name:SAMUEL-CASH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:PO BOX 209
Mailing Address - Street 2:
Mailing Address - City:LILESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28091-0209
Mailing Address - Country:US
Mailing Address - Phone:704-287-8990
Mailing Address - Fax:
Practice Address - Street 1:307 N GREENE ST
Practice Address - Street 2:
Practice Address - City:WADESBORO
Practice Address - State:NC
Practice Address - Zip Code:28170-2182
Practice Address - Country:US
Practice Address - Phone:704-287-8990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-02
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC73231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC899018KMedicaid