MEDICARE: ERICA DANIELLE SAMPSON

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	124Q00000X	Dental Hygienist

General Provider Information

NPI Number	:	1548821697
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERICA DANIELLE SAMPSON

Provider Business Mailing Address
First Line	:	715 N OKLAHOMA AVE
Second Line	:
City	:	TAHLEQUAH
State	:	OK
Zip	:	74464-2411
Country	:	US
Telephone Number	:	918-207-8148
Fax Number	:

Provider Business Practice Location Address
First Line	:	715 N OKLAHOMA AVE
Second Line	:
City	:	TAHLEQUAH
State	:	OK
Zip	:	74464-2411
Country	:	US
Telephone Number	:	918-207-8148
Fax Number	:

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

Provider Enumeration Date	:	06/27/2019
Last Update Date	:	06/27/2019

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