Provider Demographics
NPI:1417330556
Name:KUFTA, SAMANTHA (DMD)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:KUFTA
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 1:0N740 MORNINGSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:WEST CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60185-2436
Mailing Address - Country:US
Mailing Address - Phone:630-965-7306
Mailing Address - Fax:
Practice Address - Street 1:4259 S BERKELEY AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60653-3030
Practice Address - Country:US
Practice Address - Phone:630-965-7306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-07
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.030217122300000X, 1223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$Medicaid