Provider Demographics
NPI:1376757138
Name:DR. SAMUEL B. MAYFIELD
Entity Type:Organization
Organization Name:DR. SAMUEL B. MAYFIELD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:B
Authorized Official - Last Name:MAYFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:228-497-9844
Mailing Address - Street 1:4341 GAUTIER VANCLEAVE RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:GAUTIER
Mailing Address - State:MS
Mailing Address - Zip Code:39553-4825
Mailing Address - Country:US
Mailing Address - Phone:228-497-9844
Mailing Address - Fax:228-497-9499
Practice Address - Street 1:4341 GAUTIER VANCLEAVE RD
Practice Address - Street 2:SUITE 3
Practice Address - City:GAUTIER
Practice Address - State:MS
Practice Address - Zip Code:39553-4825
Practice Address - Country:US
Practice Address - Phone:228-497-9844
Practice Address - Fax:228-497-9499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS031711223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS=========OtherORTHODONTICS