Provider Demographics
NPI:1659944379
Name:DILLARD, SAMUEL L
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:L
Last Name:DILLARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3112 BEGOLE ST
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48504-2900
Mailing Address - Country:US
Mailing Address - Phone:810-893-3076
Mailing Address - Fax:
Practice Address - Street 1:420 W 5TH AVE
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-2445
Practice Address - Country:US
Practice Address - Phone:810-893-3076
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-20
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator