Provider Demographics
NPI:1073783478
Name:TANCREDI, SAMUEL ALBERT (DDS)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:ALBERT
Last Name:TANCREDI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10972 ALLISONVILLE RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46038-2637
Mailing Address - Country:US
Mailing Address - Phone:317-913-2363
Mailing Address - Fax:317-913-2360
Practice Address - Street 1:9240 N MERIDIAN ST
Practice Address - Street 2:STE. 300
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-1880
Practice Address - Country:US
Practice Address - Phone:317-846-7377
Practice Address - Fax:317-846-8566
Is Sole Proprietor?:No
Enumeration Date:2008-03-03
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010688A1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200895780Medicaid
IN060320EMedicare PIN