Provider Demographics
NPI:1124578356
Name:SAM, SAMANTHA MARCH'E (RDH)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:MARCH'E
Last Name:SAM
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 221
Mailing Address - Street 2:
Mailing Address - City:KIRTLAND
Mailing Address - State:NM
Mailing Address - Zip Code:87417-0221
Mailing Address - Country:US
Mailing Address - Phone:602-329-0927
Mailing Address - Fax:
Practice Address - Street 1:1996 DOUGS PARK ROAD
Practice Address - Street 2:
Practice Address - City:CAMP VERDE
Practice Address - State:AZ
Practice Address - Zip Code:86322
Practice Address - Country:US
Practice Address - Phone:928-567-1832
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-12
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZH008389124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist