Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223D0001X | Dental Public Health | DN1857001 | MA |
NPI | 1376061838 |
---|---|
Provider Name | Dr. Shan Lo |
First Address | Boston, MA 02116-5718 |
Second Address | Boston, MA 02111-2511 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 05/09/2017 |
Last Update Date | 05/09/2017 |