Provider Demographics
NPI:1427892306
Name:TETLAK, SAMANTHA (DMD)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:TETLAK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3823 S OSPREY AVE
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34239-6803
Mailing Address - Country:US
Mailing Address - Phone:941-326-2022
Mailing Address - Fax:
Practice Address - Street 1:3823 S OSPREY AVE
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-6803
Practice Address - Country:US
Practice Address - Phone:941-326-2022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-24
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN29162122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist