Healthcare Provider Details

I. General information

NPI: 1629194535
Provider Name (Legal Business Name): SAMANTHA LYNN HOLDER D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 06/05/2020
Certification Date: 06/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7595 E MCDONALD DR STE 110
SCOTTSDALE AZ
85250-6080
US

IV. Provider business mailing address

653 E SIPAPU DR
GILBERT AZ
85297-1393
US

V. Phone/Fax

Practice location:
  • Phone: 480-757-0007
  • Fax:
Mailing address:
  • Phone: 708-334-6036
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD009694
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number19027057
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: