Healthcare Provider Details

I. General information

NPI: 1962617548
Provider Name (Legal Business Name): SAMSON S DEREBE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6044 MARTIN LUTHER KING WAY SO SUITE#101
SEATTLE WA
98118-3179
US

IV. Provider business mailing address

6044 MARTIN LUTHER KING WAY SO SUITE #101
SEATTLE WA
98118-3179
US

V. Phone/Fax

Practice location:
  • Phone: 206-760-9571
  • Fax: 206-760-9627
Mailing address:
  • Phone: 206-760-9571
  • Fax: 206-760-9627

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE00008442
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: