Provider Demographics
NPI:1528147394
Name:SAMPLE, STEVEN DWIGHT (DDS)
Entity type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:DWIGHT
Last Name:SAMPLE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 LULLWATER RD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31707-3180
Mailing Address - Country:US
Mailing Address - Phone:229-439-8896
Mailing Address - Fax:229-435-4773
Practice Address - Street 1:2301 LULLWATER RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707-3180
Practice Address - Country:US
Practice Address - Phone:229-439-8896
Practice Address - Fax:229-435-4773
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0092881223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry