Provider Demographics
NPI:1265698039
Name:PAGE, SAMUEL C (DMD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:C
Last Name:PAGE
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 1:143 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JEROME
Mailing Address - State:ID
Mailing Address - Zip Code:83338-2332
Mailing Address - Country:US
Mailing Address - Phone:208-324-7007
Mailing Address - Fax:208-324-7540
Practice Address - Street 1:143 E MAIN ST
Practice Address - Street 2:
Practice Address - City:JEROME
Practice Address - State:ID
Practice Address - Zip Code:83338-2332
Practice Address - Country:US
Practice Address - Phone:208-324-7007
Practice Address - Fax:208-324-7540
Is Sole Proprietor?:No
Enumeration Date:2008-07-31
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD41751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice