Provider Demographics
NPI:1982617478
Name:SAM, SIMA (DDS)
Entity Type:Individual
Prefix:DR
First Name:SIMA
Middle Name:
Last Name:SAM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2210 HASSELL RD APT 203
Mailing Address - Street 2:
Mailing Address - City:HOFFMAN ESTATES
Mailing Address - State:IL
Mailing Address - Zip Code:60195-2131
Mailing Address - Country:US
Mailing Address - Phone:630-267-1476
Mailing Address - Fax:
Practice Address - Street 1:1200 W STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61102-2112
Practice Address - Country:US
Practice Address - Phone:815-490-1600
Practice Address - Fax:815-490-1625
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190259931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019025993OtherLICENSE
IL319014644OtherCONTROLLED SUBSTANCE
ILBS82011573OtherDEA