Provider Demographics
NPI:1285832147
Name:SAMFORD, MICHELLE NICOLE (RDH)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:NICOLE
Last Name:SAMFORD
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:BLDG 2441 21ST STREET
Mailing Address - Street 2:US ARMY DENTAL ACTIVITY
Mailing Address - City:FORT CAMPBELL
Mailing Address - State:KY
Mailing Address - Zip Code:42240-1251
Mailing Address - Country:US
Mailing Address - Phone:270-798-8977
Mailing Address - Fax:270-956-0266
Practice Address - Street 1:BLDG 2441 21ST STREET
Practice Address - Street 2:US ARMY DENTAL ACTIVITY
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42240-1251
Practice Address - Country:US
Practice Address - Phone:270-798-8977
Practice Address - Fax:270-956-0266
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3575124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist