Provider Demographics
NPI:1225169675
Name:SAMUELSON, SCOTT A (DDS)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:A
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 1:3624 N HILLS DR
Mailing Address - Street 2:SUITE C-103
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-2415
Mailing Address - Country:US
Mailing Address - Phone:512-345-2425
Mailing Address - Fax:512-345-1398
Practice Address - Street 1:3624 N HILLS DR
Practice Address - Street 2:SUITE C-103
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-2415
Practice Address - Country:US
Practice Address - Phone:512-345-2425
Practice Address - Fax:512-345-1398
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12385122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist