Provider Demographics
NPI:1497977037
Name:SAMBUCHINO, KEVIN R (DMD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:R
Last Name:SAMBUCHINO
Suffix:
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 1:4944 PEACH ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16509-2012
Mailing Address - Country:US
Mailing Address - Phone:814-864-7511
Mailing Address - Fax:814-866-1565
Practice Address - Street 1:4944 PEACH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16509-2012
Practice Address - Country:US
Practice Address - Phone:814-864-7511
Practice Address - Fax:814-866-1565
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA0313051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice