Provider Demographics
NPI:1962617548
Name:DEREBE, SAMSON S (DDS)
Entity type:Individual
Prefix:DR
First Name:SAMSON
Middle Name:S
Last Name:DEREBE
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 1:6044 MARTIN LUTHER KING WAY SO
Mailing Address - Street 2:SUITE #101
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98118-3179
Mailing Address - Country:US
Mailing Address - Phone:206-760-9571
Mailing Address - Fax:206-760-9627
Practice Address - Street 1:6044 MARTIN LUTHER KING WAY SO
Practice Address - Street 2:SUITE#101
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98118-3179
Practice Address - Country:US
Practice Address - Phone:206-760-9571
Practice Address - Fax:206-760-9627
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00008442122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist