Provider Demographics
NPI:1689379240
Name:MANDEL, SAMANTHA PAIGE (DDS)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:PAIGE
Last Name:MANDEL
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 1:3641 BRYCE DR
Mailing Address - Street 2:
Mailing Address - City:HUDSONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49426-8535
Mailing Address - Country:US
Mailing Address - Phone:734-776-1047
Mailing Address - Fax:
Practice Address - Street 1:2201 S GETTY ST
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-1207
Practice Address - Country:US
Practice Address - Phone:231-739-9315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-03
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI2901601846122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program