MEDICARE: DR. SAMUEL THOMAS BANDER DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	12766	MI

General Provider Information

NPI Number	:	1336272749
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SAMUEL THOMAS BANDER DDS

Provider Business Mailing Address
First Line	:	1151 EAST PARIS AVE SE
Second Line	:	SUITE 100
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49546-3605
Country	:	US
Telephone Number	:	616-949-5980
Fax Number	:	616-949-5981

Provider Business Practice Location Address
First Line	:	1151 EAST PARIS AVE SE
Second Line	:	SUITE 100
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49546-3605
Country	:	US
Telephone Number	:	616-949-5980
Fax Number	:	616-949-5981

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/14/2007
Last Update Date	:	07/18/2024

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