Provider Demographics
NPI:1871679415
Name:ZWETCHKENBAUM, SAMUEL R (DDS)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:R
Last Name:ZWETCHKENBAUM
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 1:375 ALLENS AVE
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-5010
Mailing Address - Country:US
Mailing Address - Phone:401-780-2511
Mailing Address - Fax:401-780-2565
Practice Address - Street 1:56 WOODBURY ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-3510
Practice Address - Country:US
Practice Address - Phone:401-588-1295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901016737122300000X, 1223P0700X
NJ22DI01757400122300000X, 1223P0700X
RIDEN02285122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI00-D-16-7370-0OtherBCBSM
MI4124472Medicaid
MI4124463Medicaid
MI4124472Medicaid
U59142Medicare UPIN