Healthcare Provider Details

I. General information

NPI: 1003592346
Provider Name (Legal Business Name): SAMANTHA L PHELIX DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2023
Last Update Date: 06/22/2023
Certification Date: 06/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4325 GERRARDSTOWN RD
INWOOD WV
25428-3449
US

IV. Provider business mailing address

4325 GERRARDSTOWN RD
INWOOD WV
25428-3449
US

V. Phone/Fax

Practice location:
  • Phone: 304-229-2181
  • Fax: 304-229-2291
Mailing address:
  • Phone: 304-229-2181
  • Fax: 304-229-2291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4633
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: