Provider Demographics
NPI:1285083279
Name:BASSIL, SAMANTHA (DDS)
Entity type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:
Last Name:BASSIL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:SOUTHWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:8176 BROOKE PARK DR APT 210
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-4062
Mailing Address - Country:US
Mailing Address - Phone:989-600-7844
Mailing Address - Fax:
Practice Address - Street 1:5425 WHITTAKER RD
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-9751
Practice Address - Country:US
Practice Address - Phone:734-480-0033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010218771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice