Healthcare Provider Details

I. General information

NPI: 1790470862
Provider Name (Legal Business Name): SAMANTHA ROSE DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2023
Last Update Date: 11/03/2023
Certification Date: 11/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10910 KINGSTON PIKE UNIT 105
KNOXVILLE TN
37934-2948
US

IV. Provider business mailing address

1424 CLEAR BROOK DR
KNOXVILLE TN
37922-6064
US

V. Phone/Fax

Practice location:
  • Phone: 865-218-9177
  • Fax:
Mailing address:
  • Phone: 954-549-3201
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12295
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: