Provider Demographics
NPI:1528633971
Name:CASEY, SAMANTHA (RDH)
Entity type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:
Last Name:CASEY
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:MISS
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:EBERHARDT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:1116 W LE MARCHE AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85023-4428
Mailing Address - Country:US
Mailing Address - Phone:602-696-7527
Mailing Address - Fax:
Practice Address - Street 1:1116 W LE MARCHE AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85023-4428
Practice Address - Country:US
Practice Address - Phone:602-696-7527
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-26
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZH007412124Q00000X
AZ174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No124Q00000XDental ProvidersDental Hygienist