Provider Demographics
NPI:1376061838
Name:LO, SHAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:SHAN
Middle Name:
Last Name:LO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 GARRISON ST APT 502
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-5718
Mailing Address - Country:US
Mailing Address - Phone:617-875-0776
Mailing Address - Fax:
Practice Address - Street 1:109 BEACH ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111-2511
Practice Address - Country:US
Practice Address - Phone:617-542-6263
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-05
Last Update Date:2017-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18570011223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Multi-Specialty