Provider Demographics
NPI:1629040126
Name:SAMS, JENNIFER BURKE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:BURKE
Last Name:SAMS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 BERGQUIST DR. SUITE 1
Mailing Address - Street 2:ATTN: CREDENTIALS (CMC)
Mailing Address - City:LACKLAND AFB
Mailing Address - State:TX
Mailing Address - Zip Code:78236-5300
Mailing Address - Country:US
Mailing Address - Phone:210-292-6647
Mailing Address - Fax:210-925-1126
Practice Address - Street 1:59TH DENTAL SQUADRON
Practice Address - Street 2:204 PAUL WAGNER DR, BUILDING 1739
Practice Address - City:KELLY USA
Practice Address - State:TX
Practice Address - Zip Code:78241
Practice Address - Country:US
Practice Address - Phone:210-292-6647
Practice Address - Fax:210-925-1126
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC 72561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice