Provider Demographics
NPI:1558415331
Name:SAMUEL, EVELYN TEAGUE (DMD)
Entity Type:Individual
Prefix:DR
First Name:EVELYN
Middle Name:TEAGUE
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5659 COLUMBIA PIKE
Mailing Address - Street 2:#100
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22041-2878
Mailing Address - Country:US
Mailing Address - Phone:314-669-5958
Mailing Address - Fax:
Practice Address - Street 1:5659 COLUMBIA PIKE
Practice Address - Street 2:# 100
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22041-2878
Practice Address - Country:US
Practice Address - Phone:314-669-5958
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL50381223G0001X
VA0401413391122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice