Provider Demographics
NPI:1952663148
Name:HALL, SAMUEL ROBERT (DMD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:ROBERT
Last Name:HALL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 S GLOSTER ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-5540
Mailing Address - Country:US
Mailing Address - Phone:662-269-4542
Mailing Address - Fax:
Practice Address - Street 1:401 S GLOSTER ST
Practice Address - Street 2:SUITE 101
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-5540
Practice Address - Country:US
Practice Address - Phone:662-269-4542
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-13
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3645-121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice