Basic Information
Provider Information
NPI: 1720599897
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: LUGO
FirstName: SABRINA
MiddleName: STEWART
NamePrefix:  
NameSuffix:  
Credential: DDS
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName: STEWART
OtherFirstName: SABRINA
OtherMiddleName: ALEXA
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential: DDS
OtherLastNameType: 1
Mailing Information
Address1: 1900 CRESTWOOD BLVD STE 211
Address2:  
City: IRONDALE
State: AL
PostalCode: 352102056
CountryCode: US
TelephoneNumber: 2052716841
FaxNumber:  
Practice Location
Address1: 3700 BLUE SPRING RD NW STE F
Address2:  
City: HUNTSVILLE
State: AL
PostalCode: 358103457
CountryCode: US
TelephoneNumber: 2568529994
FaxNumber: 2052716836
Other Information
ProviderEnumerationDate: 10/17/2017
LastUpdateDate: 10/17/2017
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
122300000X6469ALY Dental ProvidersDentist 

No ID Information.


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