Provider Demographics
NPI:1629558762
Name:DR SAM DENTAL PC
Entity Type:Organization
Organization Name:DR SAM DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:OSOBU
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:312-493-6089
Mailing Address - Street 1:2315 W HARRISON ST APT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3578
Mailing Address - Country:US
Mailing Address - Phone:312-493-6089
Mailing Address - Fax:
Practice Address - Street 1:3111 W ARMITAGE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-3818
Practice Address - Country:US
Practice Address - Phone:773-342-8493
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-17
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190304981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty