Basic Information
Provider Information
NPI: 1003805516
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: LURIE
FirstName: ALAN
MiddleName: G
NamePrefix: DR.
NameSuffix:  
Credential: DDS
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 263 FARMINGTON AVE
Address2: UCONN HEALTH CENTER MC2110
City: FARMINGTON
State: CT
PostalCode: 060300001
CountryCode: US
TelephoneNumber: 8606792453
FaxNumber: 8606792756
Practice Location
Address1: 263 FARMINGTON AVE
Address2: UCONN HEALTH CENTER MC2110
City: FARMINGTON
State: CT
PostalCode: 060300001
CountryCode: US
TelephoneNumber: 8606792453
FaxNumber: 8606792756
Other Information
ProviderEnumerationDate: 10/18/2005
LastUpdateDate: 07/08/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1223X0008X4751CTY Dental ProvidersDentistOral and Maxillofacial Radiology

No ID Information.


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