Provider Demographics
NPI:1891920542
Name:SAMUEL, WALTER VINCENT (DDS)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:VINCENT
Last Name:SAMUEL
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 1:2605 64TH AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-7403
Mailing Address - Country:US
Mailing Address - Phone:701-799-4381
Mailing Address - Fax:
Practice Address - Street 1:2605 64TH AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-7403
Practice Address - Country:US
Practice Address - Phone:701-799-4381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-26
Last Update Date:2009-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program