Provider Demographics
NPI:1659468361
Name:SAMANO, IVAN MARK (DDS)
Entity Type:Individual
Prefix:DR
First Name:IVAN
Middle Name:MARK
Last Name:SAMANO
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 1:50 W BIG BEAVER
Mailing Address - Street 2:STE 100 A
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304
Mailing Address - Country:US
Mailing Address - Phone:248-290-2900
Mailing Address - Fax:248-290-2904
Practice Address - Street 1:50 W BIG BEAVER
Practice Address - Street 2:STE 100 A
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48304
Practice Address - Country:US
Practice Address - Phone:248-290-2900
Practice Address - Fax:248-290-2904
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI18371122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1811510OtherUNITED CONCORDIA
MI0183710OtherBCBS
MI4852555Medicaid