Samuel Tack

Primary specialty

Oral and Maxillofacial Surgery (Dentist)Taxonomy code 1223S0112X

License

0438000489 Issued in VA

Practice address

520 N 12TH St
Richmond, VA 23298-5064

Phone

(804) 628-7146

NPI assigned

Feb 18, 2017

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in VA

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Vcu Oral-Facial Surgery and Services LLC

  • Oral & Maxillofacial Surgery (D.M.D.)
  • Richmond, VA
  • NPI 1215502125

  Oral and Maxillofacial Surgery

  Medicare reassignment NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1487376000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1694390400000",
    "number": "1033658406",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "520 N 12TH ST",
            "city": "RICHMOND",
            "state": "VA",
            "postal_code": "232985064",
            "telephone_number": "804-628-7146"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "520 N 12TH ST",
            "city": "RICHMOND",
            "state": "VA",
            "postal_code": "232985064",
            "telephone_number": "804-628-7146"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "27005 76th Ave",
            "address_purpose": "LOCATION",
            "city": "New Hyde Park",
            "state": "NY",
            "postal_code": "110401402",
            "country_code": "US",
            "telephone_number": "718-470-7000",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "TACK",
        "first_name": "SAMUEL",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2017-02-18",
        "last_updated": "2023-09-11",
        "certification_date": "2023-09-11",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": "VA",
            "license": "0401415733",
            "primary": false
        },
        {
            "code": "1223S0112X",
            "taxonomy_group": "",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "VA",
            "license": "0438000489",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Stella Bridget Tabassian, MD
• Fausta Tabe, O.D.
• Benjamin Leonard Taber, MD
• Mina Tabibi, PA-C
• Marjorie Tacey
• Tadesse G Tadesse
• Maheder Getachew Tafesse, RN
• Tag Services, Inc.
• Khalid Taha, MD
• Charlene Tai, PH.D

• Oral and Maxillofacial Surgery (Dentist) in Richmond, VA
• Providers in Richmond, VA by specialty
• Oral and Maxillofacial Surgery (Dentist) in Virginia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 11, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.