Provider Demographics
NPI:1548821697
Name:SAMPSON, ERICA DANIELLE
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:DANIELLE
Last Name:SAMPSON
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 1:715 N OKLAHOMA AVE
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-2411
Mailing Address - Country:US
Mailing Address - Phone:918-207-8148
Mailing Address - Fax:
Practice Address - Street 1:715 N OKLAHOMA AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-2411
Practice Address - Country:US
Practice Address - Phone:918-207-8148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-27
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist