Provider Demographics
NPI:1326298753
Name:ANDISCO, SAMANTA (DMD)
Entity Type:Individual
Prefix:DR
First Name:SAMANTA
Middle Name:
Last Name:ANDISCO
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 1:9500 BONITA BEACH RD SE STE 301
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34135-4698
Mailing Address - Country:US
Mailing Address - Phone:239-319-2440
Mailing Address - Fax:239-319-2440
Practice Address - Street 1:19240 QUESADA AVE
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33948-3126
Practice Address - Country:US
Practice Address - Phone:941-743-7435
Practice Address - Fax:941-743-7429
Is Sole Proprietor?:No
Enumeration Date:2008-09-23
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN175881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice