Provider Demographics
NPI:1174639983
Name:ROY, SAMUEL JONATHAN (D D S M D)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:JONATHAN
Last Name:ROY
Suffix:
Gender:M
Credentials:D D S M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 KINGSBRIDGE ROAD
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28144
Mailing Address - Country:US
Mailing Address - Phone:704-680-3078
Mailing Address - Fax:
Practice Address - Street 1:330 JAKE ALEXANDER BLVD W
Practice Address - Street 2:SUITE 103
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28147-1384
Practice Address - Country:US
Practice Address - Phone:704-754-2679
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery