Provider Demographics
NPI:1477003531
Name:DENTAL IMPLANT & PERIODONTAL SURGEONS OF MAINE LINE, P.C.
Entity Type:Organization
Organization Name:DENTAL IMPLANT & PERIODONTAL SURGEONS OF MAINE LINE, P.C.
Other - Org Name:SAM B. KHOURY, D.D.S., M.S.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PERIODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMER
Authorized Official - Middle Name:B
Authorized Official - Last Name:KHOURY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:610-500-0610
Mailing Address - Street 1:107 COMMONS CT
Mailing Address - Street 2:
Mailing Address - City:CHADDS FORD
Mailing Address - State:PA
Mailing Address - Zip Code:19317-9708
Mailing Address - Country:US
Mailing Address - Phone:610-500-0610
Mailing Address - Fax:
Practice Address - Street 1:107 COMMONS CT
Practice Address - Street 2:
Practice Address - City:CHADDS FORD
Practice Address - State:PA
Practice Address - Zip Code:19317
Practice Address - Country:US
Practice Address - Phone:610-500-0610
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-12
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0374201223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty