Provider Demographics
NPI:1205693595
Name:DELA ROSA, SAMANTHA ERICA BANZON (DDS)
Entity type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:ERICA BANZON
Last Name:DELA ROSA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:184 CHANNI LOOP
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94506-5025
Mailing Address - Country:US
Mailing Address - Phone:925-786-0359
Mailing Address - Fax:
Practice Address - Street 1:47000 WARM SPRINGS BLVD
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94539-7467
Practice Address - Country:US
Practice Address - Phone:510-226-0988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-04
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS109078122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist