Healthcare Provider Details

I. General information

NPI: 1104150168
Provider Name (Legal Business Name): SAMUEL P HUTAGALUNG TAM DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2009
Last Update Date: 09/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 WALNUT ST APT 6C
PHILADELPHIA PA
19103-5600
US

IV. Provider business mailing address

2020 WALNUT ST APT 6C
PHILADELPHIA PA
19103-5600
US

V. Phone/Fax

Practice location:
  • Phone: 267-467-0092
  • Fax:
Mailing address:
  • Phone: 267-467-0092
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS038083
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: