Provider Demographics
NPI:1326561200
Name:SAM, SUMITA SUSAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:SUMITA
Middle Name:SUSAN
Last Name:SAM
Suffix:
Gender:F
Credentials:DDS
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 100414
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32610-0414
Mailing Address - Country:US
Mailing Address - Phone:352-273-6695
Mailing Address - Fax:352-294-5310
Practice Address - Street 1:1395 CENTER DR RM D8-6
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3006
Practice Address - Country:US
Practice Address - Phone:352-273-6703
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-21
Last Update Date:2024-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2910223901223G0001X
FLDTP8051223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
No1223G0001XDental ProvidersDentistGeneral Practice