Healthcare Provider Details

I. General information

NPI: 1700378221
Provider Name (Legal Business Name): SANDY LOR DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2018
Last Update Date: 07/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 MAIN ST
JAFFREY NH
03452
US

IV. Provider business mailing address

123 MAIN ST
JAFFREY NH
03452-7104
US

V. Phone/Fax

Practice location:
  • Phone: 603-532-8720
  • Fax: 603-532-5618
Mailing address:
  • Phone: 603-532-8720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN1857972
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number04434
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: