Provider Demographics
NPI:1710033618
Name:SAMUEL, ALAN LEE (DDS)
Entity Type:Individual
Prefix:DR
First Name:ALAN
Middle Name:LEE
Last Name:SAMUEL
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 1:16 36TH PL UNIT A
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90803-2635
Mailing Address - Country:US
Mailing Address - Phone:707-834-4017
Mailing Address - Fax:
Practice Address - Street 1:615 HARRIS ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95503-4447
Practice Address - Country:US
Practice Address - Phone:707-442-1754
Practice Address - Fax:707-442-1755
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA248521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA24852OtherDENTAL LICSENS