Healthcare Provider Details

I. General information

NPI: 1114763729
Provider Name (Legal Business Name): SAM ZHAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2024
Last Update Date: 12/20/2025
Certification Date: 12/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

690 BARNES BLVD
JOINT BASE LEWIS MCCHORD WA
98438-1303
US

IV. Provider business mailing address

1137 PALISADE BLVD
DUPONT WA
98327-9749
US

V. Phone/Fax

Practice location:
  • Phone: 253-982-5505
  • Fax:
Mailing address:
  • Phone: 716-238-0719
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDENT.DE.70035415
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number14025093-9926
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: