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General NPI Number Information
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NPI Number | 1992046205
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Entity Type | Organization
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Legal Business Name | SAM DAUAHERA DDS PC
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Dates
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Enumeration Date | 03/12/2013
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Last Update Date | 03/12/2013
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Provider Practice Location Address
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Address Line | 5131 W DEVON AVE
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City | CHICAGO
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State | IL
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Zip | 60646-4217
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Country | US
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Telephone | 773-631-8717
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Fax | 773-631-7781
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Provider Business Mailing Address
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Address Line | 5131 W DEVON AVE
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City | CHICAGO
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State | IL
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Zip | 60646-4217
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Country | US
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Telephone | 773-631-8717
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Fax | 773-631-7781
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Authorized Official
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Title or Position | OWNER
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Name | DR. SAM DAUAHERA
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Credential | DDS
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Telephone | 773-456-5659
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 019027577
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License Number State | IL
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