Healthcare Provider Details

I. General information

NPI: 1730853771
Provider Name (Legal Business Name): SAMANTHA THOMAS DDS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2021
Last Update Date: 03/23/2022
Certification Date: 03/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

906 E OHIO ST
CLINTON MO
64735-2306
US

IV. Provider business mailing address

1306 N VANSANT RD
CLINTON MO
64735-9303
US

V. Phone/Fax

Practice location:
  • Phone: 417-438-5924
  • Fax:
Mailing address:
  • Phone: 417-438-5924
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. SAMANTHA L MAHONEY
Title or Position: DENTIST
Credential: DDS
Phone: 417-438-5924