Provider Demographics
NPI:1992499289
Name:SAM, JEFFREY PETER
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:PETER
Last Name:SAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 SEPTEMBER LN
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:CT
Mailing Address - Zip Code:06484-5753
Mailing Address - Country:US
Mailing Address - Phone:203-414-7782
Mailing Address - Fax:
Practice Address - Street 1:122 AMITY RD
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06515-1405
Practice Address - Country:US
Practice Address - Phone:203-389-9600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-08
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT13806122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist