Provider Demographics
NPI:1508412792
Name:WADE, SAMUEL R (DDS)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:R
Last Name:WADE
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 1:5817 MELSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-2117
Mailing Address - Country:US
Mailing Address - Phone:214-906-1562
Mailing Address - Fax:
Practice Address - Street 1:9901 VALLEY RANCH PKWY E STE 1020
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75063-7179
Practice Address - Country:US
Practice Address - Phone:972-869-5966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-13
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX356291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice