Provider Demographics
NPI:1396194460
Name:JEFFERY, SAMANTHA M (DMD)
Entity Type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:M
Last Name:JEFFERY
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 1:5738 W BELMONT AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60634-5208
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5222 US-51 N
Practice Address - Street 2:
Practice Address - City:MERCER
Practice Address - State:WI
Practice Address - Zip Code:54548
Practice Address - Country:US
Practice Address - Phone:715-476-3432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-08
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL319.0199801223G0001X
WI1002012-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice