Provider Demographics
NPI:1215641642
Name:SAM, SAVANNA LEIGH (EPDH/RDH)
Entity type:Individual
Prefix:
First Name:SAVANNA
Middle Name:LEIGH
Last Name:SAM
Suffix:
Gender:F
Credentials:EPDH/RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3837 20TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-3548
Mailing Address - Country:US
Mailing Address - Phone:360-701-1994
Mailing Address - Fax:
Practice Address - Street 1:610 HAWTHORNE AVE SE STE 200
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-5378
Practice Address - Country:US
Practice Address - Phone:800-525-6800
Practice Address - Fax:503-581-0043
Is Sole Proprietor?:No
Enumeration Date:2023-01-10
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH8571124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist