Healthcare Provider Details

I. General information

NPI: 1962198168
Provider Name (Legal Business Name): SAMUEL GUERRA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2023
Last Update Date: 04/12/2023
Certification Date: 04/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5274 CLEVELAND AVE
COLUMBUS OH
43231-4781
US

IV. Provider business mailing address

1981 SUMMIT ST APT A
COLUMBUS OH
43201-1521
US

V. Phone/Fax

Practice location:
  • Phone: 614-426-4556
  • Fax:
Mailing address:
  • Phone: 614-218-2763
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: