Provider Demographics
NPI:1760798979
Name:SAMA, KISHORE (BDS, MSD)
Entity Type:Individual
Prefix:DR
First Name:KISHORE
Middle Name:
Last Name:SAMA
Suffix:
Gender:M
Credentials:BDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 W WILLIAM CANNON DR
Mailing Address - Street 2:STE 401
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-5468
Mailing Address - Country:US
Mailing Address - Phone:512-445-5811
Mailing Address - Fax:
Practice Address - Street 1:1110 W WILLIAM CANNON DR STE 401
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-5498
Practice Address - Country:US
Practice Address - Phone:512-445-5811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-25
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX284881223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics