Provider Demographics
NPI:1477034031
Name:CLYDE, SAMUEL LUKE (DMD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:LUKE
Last Name:CLYDE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 S GENEVA RD UNIT C201
Mailing Address - Street 2:
Mailing Address - City:VINEYARD
Mailing Address - State:UT
Mailing Address - Zip Code:84058-5388
Mailing Address - Country:US
Mailing Address - Phone:907-982-5792
Mailing Address - Fax:
Practice Address - Street 1:143 E 200 S
Practice Address - Street 2:
Practice Address - City:SPRINGVILLE
Practice Address - State:UT
Practice Address - Zip Code:84663-1915
Practice Address - Country:US
Practice Address - Phone:801-489-4541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-22
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10832862-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice