Provider Demographics
NPI:1093601809
Name:KITCHEN, SAMANTHA
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:KITCHEN
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28294 FERRY RD APT 269
Mailing Address - Street 2:
Mailing Address - City:WARRENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60555-4065
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:444 W ARMY TRAIL RD
Practice Address - Street 2:
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108-1379
Practice Address - Country:US
Practice Address - Phone:630-387-9764
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-17
Last Update Date:2025-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.036156122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist