Healthcare Provider Details

I. General information

NPI: 1699065169
Provider Name (Legal Business Name): MATTHEW SAMUEL LUPU DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2011
Last Update Date: 04/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4011 WEST FLAGLER ST. SUITE #202
MIAMI FL
33134
US

IV. Provider business mailing address

7410 COQUINA DR
NORTH BAY VILLAGE FL
33141-4023
US

V. Phone/Fax

Practice location:
  • Phone: 305-541-3030
  • Fax:
Mailing address:
  • Phone: 305-757-4173
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN19242
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: