Healthcare Provider Details

I. General information

NPI: 1750355194
Provider Name (Legal Business Name): SAMUEL ALAN PASSO D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 07/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7131 MOHAWK LANE
INDIANAPOLIS IN
46260
US

IV. Provider business mailing address

7131 MOHAWK LANE
INDIANAPOLIS IN
46260
US

V. Phone/Fax

Practice location:
  • Phone: 502-767-0027
  • Fax: 270-798-8633
Mailing address:
  • Phone: 502-767-0027
  • Fax: 270-798-8633

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number2901012290
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number040718
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDS020240L
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number5321
License Number StateNE
# 5
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number019-020471
License Number StateIL
# 6
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number12008878
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: