Provider Demographics
NPI:1891241527
Name:DIDOMENICO, SAMANTHA RAE (DDS)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:RAE
Last Name:DIDOMENICO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:RAE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:1119 W 11TH ST
Mailing Address - Street 2:
Mailing Address - City:LA JUNTA
Mailing Address - State:CO
Mailing Address - Zip Code:81050-2608
Mailing Address - Country:US
Mailing Address - Phone:972-672-4468
Mailing Address - Fax:
Practice Address - Street 1:245 VINE AVE
Practice Address - Street 2:
Practice Address - City:LAS ANIMAS
Practice Address - State:CO
Practice Address - Zip Code:81054
Practice Address - Country:US
Practice Address - Phone:719-456-2653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2029301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice