Provider Demographics
NPI:1093839748
Name:SAMUELSON, JAY D (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:D
Last Name:SAMUELSON
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 1:13808 W MAPLE RD
Mailing Address - Street 2:SUITE112
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68164-6231
Mailing Address - Country:US
Mailing Address - Phone:402-445-4647
Mailing Address - Fax:402-445-8370
Practice Address - Street 1:13808 W MAPLE RD
Practice Address - Street 2:SUITE112
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68164-6231
Practice Address - Country:US
Practice Address - Phone:402-445-4647
Practice Address - Fax:402-445-8370
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE60781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice