Provider Demographics
NPI:1104150168
Name:HUTAGALUNG TAM, SAMUEL P (DMD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:P
Last Name:HUTAGALUNG TAM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 WALNUT ST APT 6C
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19103-5600
Mailing Address - Country:US
Mailing Address - Phone:267-467-0092
Mailing Address - Fax:
Practice Address - Street 1:2020 WALNUT ST APT 6C
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19103-5600
Practice Address - Country:US
Practice Address - Phone:267-467-0092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-23
Last Update Date:2009-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS038083122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist