Provider Demographics
NPI:1164192803
Name:LEW B. SAMPLE, DMD, MS, PC
Entity Type:Organization
Organization Name:LEW B. SAMPLE, DMD, MS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LLEWELLYN
Authorized Official - Middle Name:BAIN
Authorized Official - Last Name:SAMPLE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:256-355-5255
Mailing Address - Street 1:2014 DANVILLE PARK DR SW
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35603-1832
Mailing Address - Country:US
Mailing Address - Phone:256-355-5255
Mailing Address - Fax:256-355-8183
Practice Address - Street 1:2014 DANVILLE PARK DR SW
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35603-1832
Practice Address - Country:US
Practice Address - Phone:256-355-5255
Practice Address - Fax:256-355-8183
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-15
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental