Provider Demographics
NPI:1841806387
Name:SAMUEL BARTLETT DDS, PLLC
Entity Type:Organization
Organization Name:SAMUEL BARTLETT DDS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORGANIZER/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BARTLETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-553-5392
Mailing Address - Street 1:3309 HEALY DR STE B
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-1474
Mailing Address - Country:US
Mailing Address - Phone:366-765-8847
Mailing Address - Fax:
Practice Address - Street 1:3309 HEALY DR STE B
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1474
Practice Address - Country:US
Practice Address - Phone:366-765-8847
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-21
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1821447350Medicaid