Provider Demographics
NPI:1992046205
Name:SAM DAUAHERA DDS PC
Entity Type:Organization
Organization Name:SAM DAUAHERA DDS PC
Other - Org Name:EDGEBROOK DENTAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAM
Authorized Official - Middle Name:
Authorized Official - Last Name:DAUAHERA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-456-5659
Mailing Address - Street 1:5131 W DEVON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-4217
Mailing Address - Country:US
Mailing Address - Phone:773-631-8717
Mailing Address - Fax:773-631-7781
Practice Address - Street 1:5131 W DEVON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-4217
Practice Address - Country:US
Practice Address - Phone:773-631-8717
Practice Address - Fax:773-631-7781
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-12
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190275771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty