Provider Demographics
NPI:1972600955
Name:BENANTI, SAMUEL GREGORY (DMD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:GREGORY
Last Name:BENANTI
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:PO BOX 489
Mailing Address - Street 2:
Mailing Address - City:TILLAMOOK
Mailing Address - State:OR
Mailing Address - Zip Code:97141-0489
Mailing Address - Country:US
Mailing Address - Phone:503-842-3900
Mailing Address - Fax:503-842-3903
Practice Address - Street 1:805 IVY AVE STE B
Practice Address - Street 2:
Practice Address - City:TILLAMOOK
Practice Address - State:OR
Practice Address - Zip Code:97141-3758
Practice Address - Country:US
Practice Address - Phone:503-842-2356
Practice Address - Fax:503-815-2636
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY73391223G0001X
ORD106311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice