Provider Demographics
NPI:1457828493
Name:SOH OF TEXAS SAMSON LIU PLLC
Entity Type:Organization
Organization Name:SOH OF TEXAS SAMSON LIU PLLC
Other - Org Name:IVY ROSE MANSFIELD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:ASHLY
Authorized Official - Middle Name:
Authorized Official - Last Name:SUNSHINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-362-4986
Mailing Address - Street 1:1422 ELBRIDGE PAYNE RD STE 240
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-8544
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2170 MATLOCK RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-3814
Practice Address - Country:US
Practice Address - Phone:682-518-5655
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOH OF TEXAS SAMSON LIU PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-10-29
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty