Healthcare Provider Details

I. General information

NPI: 1528822160
Provider Name (Legal Business Name): SAMANTHA SOLACK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2024
Last Update Date: 02/13/2024
Certification Date: 02/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

169 N PENNSYLVANIA AVE
WILKES BARRE PA
18701-3603
US

IV. Provider business mailing address

1333 SHOEMAKER AVE
WEST WYOMING PA
18644-1018
US

V. Phone/Fax

Practice location:
  • Phone: 570-491-0126
  • Fax:
Mailing address:
  • Phone: 570-498-4907
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH071003
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: