Provider Demographics
NPI:1851593164
Name:BART A. SAMUELSON DDS, PC
Entity Type:Organization
Organization Name:BART A. SAMUELSON DDS, PC
Other - Org Name:BLACK HILLS AREA DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER DENTIST PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BART
Authorized Official - Middle Name:A
Authorized Official - Last Name:SAMUELSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:605-348-4657
Mailing Address - Street 1:200 FEDERAL AVE
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-2326
Mailing Address - Country:US
Mailing Address - Phone:605-348-4657
Mailing Address - Fax:
Practice Address - Street 1:200 FEDERAL AVE
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-2326
Practice Address - Country:US
Practice Address - Phone:605-348-4657
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDD0607122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty