Healthcare Provider Details

I. General information

NPI: 1376383307
Provider Name (Legal Business Name): SAMANTHA MICHELLE ROSE DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2024
Last Update Date: 05/28/2024
Certification Date: 05/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

191 MAIN ST
SPRINGFIELD NE
68059-2530
US

IV. Provider business mailing address

4431 S 57TH ST
LINCOLN NE
68516-1402
US

V. Phone/Fax

Practice location:
  • Phone: 402-253-2868
  • Fax:
Mailing address:
  • Phone: 402-853-4051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number8006
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: