Provider Demographics
NPI:1770594632
Name:DORN, SAMUEL O (DDS)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:O
Last Name:DORN
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 1:8200 W SUNRISE BLVD
Mailing Address - Street 2:SUITE B-2
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33322-5426
Mailing Address - Country:US
Mailing Address - Phone:954-474-8787
Mailing Address - Fax:954-474-1557
Practice Address - Street 1:8200 W SUNRISE BLVD
Practice Address - Street 2:SUITE B-2
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33322-5426
Practice Address - Country:US
Practice Address - Phone:954-474-8787
Practice Address - Fax:954-474-1557
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 67701223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics