Provider Demographics
NPI:1811570658
Name:GUAN, SAMANTHA TING
Entity type:Individual
Prefix:MISS
First Name:SAMANTHA
Middle Name:TING
Last Name:GUAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 BEALE ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02170-3228
Mailing Address - Country:US
Mailing Address - Phone:857-756-0349
Mailing Address - Fax:
Practice Address - Street 1:6595C ROOSEVELT BLVD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19149-2918
Practice Address - Country:US
Practice Address - Phone:215-743-3700
Practice Address - Fax:215-743-3715
Is Sole Proprietor?:No
Enumeration Date:2021-04-29
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE77141223G0001X
NJ22DI030275001223P0221X
PADS0435091223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice