Healthcare Provider Details

I. General information

NPI: 1285832147
Provider Name (Legal Business Name): MICHELLE NICOLE SAMFORD RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2007
Last Update Date: 06/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BLDG 2441 21ST STREET US ARMY DENTAL ACTIVITY
FORT CAMPBELL KY
42240-1251
US

IV. Provider business mailing address

BLDG 2441 21ST STREET US ARMY DENTAL ACTIVITY
FORT CAMPBELL KY
42240-1251
US

V. Phone/Fax

Practice location:
  • Phone: 270-798-8977
  • Fax: 270-956-0266
Mailing address:
  • Phone: 270-798-8977
  • Fax: 270-956-0266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number3575
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: