Provider Demographics
NPI:1407107584
Name:SAMAR DENTAL GROUP
Entity Type:Organization
Organization Name:SAMAR DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:OSPINA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:305-513-4116
Mailing Address - Street 1:8601 NW 58TH ST
Mailing Address - Street 2:STE. 102
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33166-3311
Mailing Address - Country:US
Mailing Address - Phone:305-513-4116
Mailing Address - Fax:786-331-8508
Practice Address - Street 1:8601 NW 58TH ST
Practice Address - Street 2:STE. 102
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33166-3311
Practice Address - Country:US
Practice Address - Phone:305-513-4116
Practice Address - Fax:786-331-8508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-28
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN17493122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0769355-00Medicaid