Healthcare Provider Details

I. General information

NPI: 1518013432
Provider Name (Legal Business Name): ELIZABETH ANN SAMORE D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 LAKE ST
OAK PARK IL
60302-2612
US

IV. Provider business mailing address

831 JACKSON AVE
RIVER FOREST IL
60305-1413
US

V. Phone/Fax

Practice location:
  • Phone: 708-848-0528
  • Fax:
Mailing address:
  • Phone: 708-209-1465
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: