Provider Demographics
NPI:1477002897
Name:MUDD, SAMANTHA LEE (DMD)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LEE
Last Name:MUDD
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:LEE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:4007 VALLEY VIEW DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40216-4221
Mailing Address - Country:US
Mailing Address - Phone:502-448-0678
Mailing Address - Fax:
Practice Address - Street 1:4007 VALLEY VIEW DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40216-4221
Practice Address - Country:US
Practice Address - Phone:502-448-0678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-27
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY9805122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1902627540Medicaid