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General NPI Number Information
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NPI Number | 1063800894
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Entity Type | Organization
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Legal Business Name | SAMANTHA L HOLDER DENTAL SERVICES LLC
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Dates
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Enumeration Date | 12/31/2014
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Last Update Date | 12/31/2014
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Provider Practice Location Address
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Address Line | 19848 S LA GRANGE RD
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City | MOKENA
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State | IL
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Zip | 60448-9339
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Country | US
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Telephone | 708-478-2550
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Fax |
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Provider Business Mailing Address
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Address Line | 19848 S LA GRANGE RD
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City | MOKENA
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State | IL
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Zip | 60448-9339
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Country | US
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Telephone | 708-478-2550
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Fax |
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Authorized Official
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Title or Position | OWNER/GENERAL DENTIST
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Name | DR. SAMANTHA HOLDER
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Credential | D.D.S.
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Telephone | 708-478-2550
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 019027057
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License Number State | IL
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