Provider Demographics
NPI:1558499335
Name:SAMPANG, MARK (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:SAMPANG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10210 W MCDOWELL RD
Mailing Address - Street 2:SUITE #140
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85392-4842
Mailing Address - Country:US
Mailing Address - Phone:623-873-0880
Mailing Address - Fax:
Practice Address - Street 1:10210 W MCDOWELL RD
Practice Address - Street 2:SUITE #140
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85392-4842
Practice Address - Country:US
Practice Address - Phone:623-873-0880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD71441223G0001X
CA55127122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist