Provider Demographics
NPI:1104360767
Name:SAM ANTOON, DMD, PA
Entity Type:Organization
Organization Name:SAM ANTOON, DMD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:OUSAMA
Authorized Official - Middle Name:ANTOON
Authorized Official - Last Name:DMD
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:972-267-5000
Mailing Address - Street 1:6521 PRESTON RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-2712
Mailing Address - Country:US
Mailing Address - Phone:972-267-5000
Mailing Address - Fax:
Practice Address - Street 1:6521 PRESTON RD
Practice Address - Street 2:SUITE 300
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75024-2712
Practice Address - Country:US
Practice Address - Phone:972-267-5000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAM ANTOON, DMD, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-12-15
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17948122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty