Healthcare Provider Details

I. General information

NPI: 1568882256
Provider Name (Legal Business Name): SAMANTHA LEEANN GERARD RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2014
Last Update Date: 04/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

195 W 14TH
RIFLE CO
81650-4700
US

IV. Provider business mailing address

195 W. 14TH STREET GARFIELD PUBLIC HEALTH
RIFLE CO
81650
US

V. Phone/Fax

Practice location:
  • Phone: 970-625-5200
  • Fax:
Mailing address:
  • Phone: 970-625-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number906373
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: