Provider Demographics
NPI:1477114452
Name:NEUROTH, SAMANTHA ELLEN (RDH)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ELLEN
Last Name:NEUROTH
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4459 N 65TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53218-5506
Mailing Address - Country:US
Mailing Address - Phone:262-765-0122
Mailing Address - Fax:
Practice Address - Street 1:3522 W LISBON AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53208-1953
Practice Address - Country:US
Practice Address - Phone:414-935-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-21
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI100344516124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist