Provider Demographics
NPI:1881656387
Name:DENTON, SAMUEL J (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:J
Last Name:DENTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:S
Other - Middle Name:JON
Other - Last Name:DENTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2441 GREAR ST NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-2749
Mailing Address - Country:US
Mailing Address - Phone:503-588-0469
Mailing Address - Fax:
Practice Address - Street 1:2441 GREAR ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-2749
Practice Address - Country:US
Practice Address - Phone:503-588-0469
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD13615207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR149161Medicaid
OR149161Medicaid