Provider Demographics
NPI:1417305327
Name:MCKENNA, SAMANTHA J (DDS)
Entity Type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:J
Last Name:MCKENNA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:J
Other - Last Name:BLAHA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15813 CW HADAN DR.
Mailing Address - Street 2:
Mailing Address - City:BENNINGTON
Mailing Address - State:NE
Mailing Address - Zip Code:68007-2017
Mailing Address - Country:US
Mailing Address - Phone:402-238-9922
Mailing Address - Fax:402-238-2424
Practice Address - Street 1:15813 CW HADAN DR.
Practice Address - Street 2:
Practice Address - City:BENNINGTON
Practice Address - State:NE
Practice Address - Zip Code:68007-2017
Practice Address - Country:US
Practice Address - Phone:402-238-9922
Practice Address - Fax:402-238-2424
Is Sole Proprietor?:No
Enumeration Date:2016-06-01
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012509A122300000X
NE74461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist