Provider Demographics
NPI:1295758969
Name:LASRIS, SAMUEL ROSS (DDS)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:ROSS
Last Name:LASRIS
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 1:395 SOUTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24541-2925
Mailing Address - Country:US
Mailing Address - Phone:434-797-2357
Mailing Address - Fax:
Practice Address - Street 1:395 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541-2925
Practice Address - Country:US
Practice Address - Phone:434-797-2357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA048841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7614062Medicaid