Provider Demographics
NPI:1639599897
Name:AHN, SAM (DMD)
Entity type:Individual
Prefix:DR
First Name:SAM
Middle Name:
Last Name:AHN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:653 COLUMBIA RD
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02125-1712
Mailing Address - Country:US
Mailing Address - Phone:617-825-9100
Mailing Address - Fax:
Practice Address - Street 1:653 COLUMBIA RD
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02125-1712
Practice Address - Country:US
Practice Address - Phone:617-825-9100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-25
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS60915122300000X
CT03679680122300000X
MADN1857100122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist