Healthcare Provider Details

I. General information

NPI: 1033658406
Provider Name (Legal Business Name): SAMUEL TACK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2017
Last Update Date: 09/11/2023
Certification Date: 09/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 N 12TH ST
RICHMOND VA
23298-5064
US

IV. Provider business mailing address

520 N 12TH ST
RICHMOND VA
23298-5064
US

V. Phone/Fax

Practice location:
  • Phone: 804-628-7146
  • Fax:
Mailing address:
  • Phone: 804-628-7146
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number0401415733
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number0438000489
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: