Provider Demographics
NPI:1720517600
Name:ABETTAN, SAM (DDS)
Entity type:Individual
Prefix:DR
First Name:SAM
Middle Name:
Last Name:ABETTAN
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 1:31 FROST LN
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:NY
Mailing Address - Zip Code:11559-1808
Mailing Address - Country:US
Mailing Address - Phone:516-295-1155
Mailing Address - Fax:
Practice Address - Street 1:31 FROST LN
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:NY
Practice Address - Zip Code:11559-1808
Practice Address - Country:US
Practice Address - Phone:516-295-1155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-05
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0606591223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty