Provider Demographics
NPI:1336272749
Name:BANDER, SAMUEL THOMAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:THOMAS
Last Name:BANDER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1151 EAST PARIS AVE SE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-3605
Mailing Address - Country:US
Mailing Address - Phone:616-949-5980
Mailing Address - Fax:616-949-5981
Practice Address - Street 1:1151 EAST PARIS AVE SE
Practice Address - Street 2:SUITE 100
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3605
Practice Address - Country:US
Practice Address - Phone:616-949-5980
Practice Address - Fax:616-949-5981
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI12766122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist