Provider Demographics
NPI:1245615327
Name:SAMPLE, ANGELA (RDH,BS)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:SAMPLE
Suffix:
Gender:F
Credentials:RDH,BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2970 31ST ST
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95817-2726
Mailing Address - Country:US
Mailing Address - Phone:313-737-4487
Mailing Address - Fax:
Practice Address - Street 1:333 LAWS AVE
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-6540
Practice Address - Country:US
Practice Address - Phone:707-468-1010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-30
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27933124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist