Provider Demographics
NPI:1124381629
Name:BAE, SAM SEOHO (MD, DDS)
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:SEOHO
Last Name:BAE
Suffix:
Gender:M
Credentials:MD, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6464 SW BORLAND RD STE D3
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-8861
Mailing Address - Country:US
Mailing Address - Phone:503-692-5654
Mailing Address - Fax:
Practice Address - Street 1:6464 SW BORLAND RD STE D3
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062
Practice Address - Country:US
Practice Address - Phone:503-692-5654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-19
Last Update Date:2019-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX33845204E00000X
MI2901020742204E00000X
TXR6146204E00000X
MI4301109828204E00000X
ORMD191912204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty