Healthcare Provider Details

I. General information

NPI: 1326353673
Provider Name (Legal Business Name): SAMANTHA M. KOFLER DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SAMANTHA A. MANIERRE DDS

II. Dates (important events)

Enumeration Date: 08/11/2010
Last Update Date: 01/10/2023
Certification Date: 01/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 W ROSE ST
WALLA WALLA WA
99362-1662
US

IV. Provider business mailing address

PO BOX 190
TOPPENISH WA
98948-0190
US

V. Phone/Fax

Practice location:
  • Phone: 509-525-0247
  • Fax: 509-522-2349
Mailing address:
  • Phone: 509-865-2395
  • Fax: 509-865-0757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE60477203
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDE60477203
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: