Provider Demographics
NPI:1639781966
Name:LASRY, SAMUEL FREDERIC (DDS)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:FREDERIC
Last Name:LASRY
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 1:1418 NEWTON ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90021-2726
Mailing Address - Country:US
Mailing Address - Phone:310-734-7705
Mailing Address - Fax:
Practice Address - Street 1:1125 S BEVERLY DR
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90035-1148
Practice Address - Country:US
Practice Address - Phone:310-734-7705
Practice Address - Fax:661-206-0223
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-18
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1045761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice