Provider Demographics
NPI:1740702091
Name:TA, SAMUEL JAMES JR (DMD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:JAMES
Last Name:TA
Suffix:JR
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 1:2354 FREEDOM BLVD APT C8
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29505-6092
Mailing Address - Country:US
Mailing Address - Phone:215-478-1659
Mailing Address - Fax:
Practice Address - Street 1:1519 HERITAGE LN
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29505-3141
Practice Address - Country:US
Practice Address - Phone:843-664-8777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-07
Last Update Date:2017-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC89731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty