Provider Demographics
NPI:1417204884
Name:LUX DENTAL FOR KIDS
Entity Type:Organization
Organization Name:LUX DENTAL FOR KIDS
Other - Org Name:LUX DENTAL FOR KIDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ABDULLAIBRAHIM
Authorized Official - Middle Name:
Authorized Official - Last Name:ABDULWAHEED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-558-5092
Mailing Address - Street 1:505 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-5834
Mailing Address - Country:US
Mailing Address - Phone:617-756-1928
Mailing Address - Fax:206-203-2845
Practice Address - Street 1:1201 BROADWAY
Practice Address - Street 2:ROOM E215
Practice Address - City:SAUGUS
Practice Address - State:MA
Practice Address - Zip Code:01906-4177
Practice Address - Country:US
Practice Address - Phone:781-558-5092
Practice Address - Fax:206-203-2845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-04
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA208271223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty