Provider Demographics
NPI:1235869199
Name:GROSS, SAMANTHA KAY (DMD)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:KAY
Last Name:GROSS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8490 EMLING RD
Mailing Address - Street 2:
Mailing Address - City:DU QUOIN
Mailing Address - State:IL
Mailing Address - Zip Code:62832-3808
Mailing Address - Country:US
Mailing Address - Phone:618-318-6112
Mailing Address - Fax:
Practice Address - Street 1:1226 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:DU QUOIN
Practice Address - State:IL
Practice Address - Zip Code:62832-3853
Practice Address - Country:US
Practice Address - Phone:618-542-8832
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-14
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0337231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice