Provider Demographics
NPI:1700090883
Name:SAMUELSON, KIM E (DMD)
Entity Type:Individual
Prefix:DR
First Name:KIM
Middle Name:E
Last Name:SAMUELSON
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:PO BOX 1288
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84014-5288
Mailing Address - Country:US
Mailing Address - Phone:801-292-6995
Mailing Address - Fax:801-292-4641
Practice Address - Street 1:80 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:UT
Practice Address - Zip Code:84014-1817
Practice Address - Country:US
Practice Address - Phone:801-292-6995
Practice Address - Fax:801-292-4641
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1380071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice