Provider Demographics
NPI:1235162124
Name:LU, SAMUEL (DMD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:
Last Name:LU
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:XUESONG
Other - Middle Name:
Other - Last Name:LU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:65 MAGNOLIA CIR
Mailing Address - Street 2:
Mailing Address - City:LONGMEADOW
Mailing Address - State:MA
Mailing Address - Zip Code:01106-2524
Mailing Address - Country:US
Mailing Address - Phone:413-567-1688
Mailing Address - Fax:
Practice Address - Street 1:50 HOLYOKE ST
Practice Address - Street 2:
Practice Address - City:HOLYOKE
Practice Address - State:MA
Practice Address - Zip Code:01040-2709
Practice Address - Country:US
Practice Address - Phone:413-538-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA198741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0299987Medicaid