Provider Demographics
NPI:1629715560
Name:LOU, KEVIN (DMD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:LOU
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 1:107 S RIVER RD APT 414
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:NH
Mailing Address - Zip Code:03110-6785
Mailing Address - Country:US
Mailing Address - Phone:770-864-6098
Mailing Address - Fax:
Practice Address - Street 1:283 BROAD ST
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03063-3160
Practice Address - Country:US
Practice Address - Phone:603-882-7312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-12
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH047431223G0001X
390200000X
MA18593741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program