Individual
SAMUEL TACK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
520 N 12TH ST, RICHMOND, VA 23298-5064
(804) 628-7146
Mailing address
520 N 12TH ST, RICHMOND, VA 23298-5064
(804) 628-7146
Taxonomy
Speciality
Code
Description
License number
State
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
Primary
0438000489
VA
390200000X
Student in an Organized Health Care Education/Training Program
0401415733
VA
Other
Enumeration date
02/18/2017
Last updated
09/11/2023
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