Provider Demographics
NPI:1255781209
Name:PERO, SAMUEL THOMAS IV (DMD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:THOMAS
Last Name:PERO
Suffix:IV
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 1:701 STATE ROAD 60 E
Mailing Address - Street 2:
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33853-4240
Mailing Address - Country:US
Mailing Address - Phone:863-676-6021
Mailing Address - Fax:
Practice Address - Street 1:701 STATE ROAD 60 E
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33853-4240
Practice Address - Country:US
Practice Address - Phone:863-676-6021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-20
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL21864122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist