Provider Demographics
NPI:1508131350
Name:SAM W. QUILLEN JR. DMD
Entity Type:Organization
Organization Name:SAM W. QUILLEN JR. DMD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAM
Authorized Official - Middle Name:WILEY
Authorized Official - Last Name:QUILLEN
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:606-855-7892
Mailing Address - Street 1:PO BOX 36
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEON
Mailing Address - State:KY
Mailing Address - Zip Code:41840-0036
Mailing Address - Country:US
Mailing Address - Phone:606-855-7892
Mailing Address - Fax:606-855-7892
Practice Address - Street 1:861 HWY 317
Practice Address - Street 2:SUITE A
Practice Address - City:NEON
Practice Address - State:KY
Practice Address - Zip Code:41840-0036
Practice Address - Country:US
Practice Address - Phone:606-855-7892
Practice Address - Fax:606-855-7892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-13
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4626122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty