Provider Demographics
NPI:1043770373
Name:SACKOS, SAMANTHA LUISE (DDS)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LUISE
Last Name:SACKOS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2258 W ROOSEVELT BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28110-3090
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2258 W ROOSEVELT BLVD STE A
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28110-3090
Practice Address - Country:US
Practice Address - Phone:704-291-7100
Practice Address - Fax:704-291-7115
Is Sole Proprietor?:No
Enumeration Date:2019-03-22
Last Update Date:2023-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD52631223G0001X
AL00066871223G0001X
NC601951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice