Healthcare Provider Details

I. General information

NPI: 1083955819
Provider Name (Legal Business Name): SAMUEL LANDRIAN DMD, MD.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2013
Last Update Date: 03/10/2020
Certification Date: 03/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6731 MADISON ST
NEW PORT RICHEY FL
34652-1928
US

IV. Provider business mailing address

6731 MADISON ST
NEW PORT RICHEY FL
34652-1928
US

V. Phone/Fax

Practice location:
  • Phone: 727-842-5180
  • Fax: 727-846-0755
Mailing address:
  • Phone: 727-842-5180
  • Fax: 727-846-0755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberME139628
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN20143
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: