Healthcare Provider Details

I. General information

NPI: 1184092231
Provider Name (Legal Business Name): SARA REBECA KANG SAMAYOA DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2015
Last Update Date: 06/18/2024
Certification Date: 06/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

836 W WELLINGTON AVE
CHICAGO IL
60657-5147
US

IV. Provider business mailing address

811 W WELLINGTON AVE
CHICAGO IL
60657-5123
US

V. Phone/Fax

Practice location:
  • Phone: 773-975-1600
  • Fax:
Mailing address:
  • Phone: 773-871-2188
  • Fax: 773-871-6353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number019.034051
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: