Provider Demographics
NPI:1366975419
Name:DR SAM DMD PC
Entity type:Organization
Organization Name:DR SAM DMD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:OSOBU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-493-6089
Mailing Address - Street 1:2120 W WASHINGTON BLVD
Mailing Address - Street 2:SUITE. 306
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-2346
Mailing Address - Country:US
Mailing Address - Phone:312-493-6089
Mailing Address - Fax:
Practice Address - Street 1:1022 E 162ND ST
Practice Address - Street 2:
Practice Address - City:SOUTH HOLLAND
Practice Address - State:IL
Practice Address - Zip Code:60473-2560
Practice Address - Country:US
Practice Address - Phone:312-493-6089
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-06
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019030498261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental