Provider Demographics
NPI:1629154018
Name:SAMUELSON, DAVID LEE (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:LEE
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 1:305 MCKINLEY
Mailing Address - Street 2:PO BOX 306
Mailing Address - City:LOWDEN
Mailing Address - State:IA
Mailing Address - Zip Code:52255
Mailing Address - Country:US
Mailing Address - Phone:563-941-5381
Mailing Address - Fax:563-941-5318
Practice Address - Street 1:305 MCKINLEY
Practice Address - Street 2:
Practice Address - City:LOWDEN
Practice Address - State:IA
Practice Address - Zip Code:52255
Practice Address - Country:US
Practice Address - Phone:563-941-5381
Practice Address - Fax:563-941-5318
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA58221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1075945Medicaid
BS3817042Medicare UPIN