Healthcare Provider Details

I. General information

NPI: 1528075231
Provider Name (Legal Business Name): SAMUEL L. LANDA D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 12/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2350 SCENIC DR
VENICE FL
34293-1510
US

IV. Provider business mailing address

310 MARTELLAGO DR
NORTH VENICE FL
34275-6706
US

V. Phone/Fax

Practice location:
  • Phone: 203-889-7421
  • Fax:
Mailing address:
  • Phone: 203-889-7421
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number007977
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License NumberDN20545
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: