Provider Demographics
NPI:1780882159
Name:NOUMBISSI, SAMMY STEFAN
Entity type:Individual
Prefix:
First Name:SAMMY
Middle Name:STEFAN
Last Name:NOUMBISSI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14921 SADDLE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:BURTONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20866-2210
Mailing Address - Country:US
Mailing Address - Phone:301-870-4553
Mailing Address - Fax:
Practice Address - Street 1:117 SAINT PATRICKS DR
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20603-4574
Practice Address - Country:US
Practice Address - Phone:301-870-4553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-06
Last Update Date:2020-03-06
Deactivation Date:2020-01-28
Deactivation Code:
Reactivation Date:2020-03-06
Provider Licenses
StateLicense IDTaxonomies
MD12911122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist