Provider Demographics
NPI:1275829681
Name:LI, SAMUEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:
Last Name:LI
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 1:162 BEELZEBUB RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074-2279
Mailing Address - Country:US
Mailing Address - Phone:917-723-0403
Mailing Address - Fax:
Practice Address - Street 1:469 BUCKLAND RD
Practice Address - Street 2:
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074
Practice Address - Country:US
Practice Address - Phone:860-644-2136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-23
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0108131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice