Healthcare Provider Details

I. General information

NPI: 1306074356
Provider Name (Legal Business Name): SAM OH,DMD,INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2009
Last Update Date: 04/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5929 EVERGREEN WAY SUITE 101
EVERETT WA
98203-6031
US

IV. Provider business mailing address

5929 EVERGREEN WAY SUITE 101
EVERETT WA
98203-6031
US

V. Phone/Fax

Practice location:
  • Phone: 360-659-8548
  • Fax: 360-653-6112
Mailing address:
  • Phone: 360-659-8548
  • Fax: 360-653-6112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number10691
License Number StateWA

VIII. Authorized Official

Name: DR. SAM S OH
Title or Position: PRESIDENT
Credential: DMD
Phone: 360-659-8548