Provider Demographics
NPI:1477177491
Name:SAM, ERISA (DMD)
Entity Type:Individual
Prefix:
First Name:ERISA
Middle Name:
Last Name:SAM
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 1:5901 W BEHREND DR APT 1113
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-6941
Mailing Address - Country:US
Mailing Address - Phone:949-702-2068
Mailing Address - Fax:
Practice Address - Street 1:10720 W INDIAN SCHOOL RD STE 55
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037-5724
Practice Address - Country:US
Practice Address - Phone:623-246-7051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-05
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0106771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice