Provider Demographics
NPI:1063076438
Name:BEN-EZRA, SAMANTHA JADE
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JADE
Last Name:BEN-EZRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 I ST NW STE 110A
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20005-6004
Mailing Address - Country:US
Mailing Address - Phone:202-548-7406
Mailing Address - Fax:
Practice Address - Street 1:1201 I ST NW STE 110A
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20005-6004
Practice Address - Country:US
Practice Address - Phone:202-548-7406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-30
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD171991223G0001X
NJ22DI027970001223G0001X
390200000X
DCDEN10020751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program