Provider Demographics
NPI:1538685698
Name:SAMUELSON, NICHOLAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:
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 1:5118 N 156TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68116-3226
Mailing Address - Country:US
Mailing Address - Phone:402-493-2268
Mailing Address - Fax:
Practice Address - Street 1:5118 N 156TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68116-3226
Practice Address - Country:US
Practice Address - Phone:402-493-2268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-20
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IADDS-09473122300000X
NE72411223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist