Provider Demographics
NPI:1457536567
Name:COPPOLA, SAMUEL JOSEPH JR (DDS)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:JOSEPH
Last Name:COPPOLA
Suffix:JR
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 1:82 COYLE STREET
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101
Mailing Address - Country:US
Mailing Address - Phone:207-775-4461
Mailing Address - Fax:
Practice Address - Street 1:82 COYLE STREET
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101
Practice Address - Country:US
Practice Address - Phone:207-775-4461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-08
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME29631223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics