Provider Demographics
NPI:1073330080
Name:SMALLMAN, SAMANTHA JANE (RDH)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JANE
Last Name:SMALLMAN
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1511 VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-2431
Mailing Address - Country:US
Mailing Address - Phone:304-541-9897
Mailing Address - Fax:
Practice Address - Street 1:410 4TH AVE
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:WV
Practice Address - Zip Code:25136-2105
Practice Address - Country:US
Practice Address - Phone:304-442-2488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-21
Last Update Date:2024-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2857124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist