Provider Demographics
NPI:1710051198
Name:GAMBINO, SAMUEL ROSS (DMD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:ROSS
Last Name:GAMBINO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:154 W SHORE DR
Mailing Address - Street 2:
Mailing Address - City:PUTNAM VALLEY
Mailing Address - State:NY
Mailing Address - Zip Code:10579-1935
Mailing Address - Country:US
Mailing Address - Phone:845-526-2197
Mailing Address - Fax:
Practice Address - Street 1:RT.6 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:MOHEGAN LAKE
Practice Address - State:NY
Practice Address - Zip Code:10547
Practice Address - Country:US
Practice Address - Phone:914-528-2222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0326781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice