Provider Demographics
NPI:1750355194
Name:PASSO, SAMUEL ALAN (DDS)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:ALAN
Last Name:PASSO
Suffix:
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 1:7131 MOHAWK LANE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260
Mailing Address - Country:US
Mailing Address - Phone:502-767-0027
Mailing Address - Fax:270-798-8633
Practice Address - Street 1:7131 MOHAWK LANE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260
Practice Address - Country:US
Practice Address - Phone:502-767-0027
Practice Address - Fax:270-798-8633
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010122901223P0300X
NY0407181223P0300X
PADS020240L1223P0300X
NE53211223P0300X
IL019-0204711223P0300X
IN120088781223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics