Provider Demographics
NPI:1215082342
Name:ZACIEWSKI, SAMANTHA RENEE (DDS)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:RENEE
Last Name:ZACIEWSKI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 ST LAWRENCE DR
Mailing Address - Street 2:SUITE 109
Mailing Address - City:TIFFIN
Mailing Address - State:OH
Mailing Address - Zip Code:44883-8312
Mailing Address - Country:US
Mailing Address - Phone:419-447-7337
Mailing Address - Fax:
Practice Address - Street 1:27 ST LAWRENCE DR
Practice Address - Street 2:SUITE 109
Practice Address - City:TIFFIN
Practice Address - State:OH
Practice Address - Zip Code:44883-8312
Practice Address - Country:US
Practice Address - Phone:419-447-7337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2015-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-0222121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2624815Medicaid
OH9182269OtherDORAL
OH04968OtherPARAMOUNT