Provider Demographics
NPI:1780626366
Name:SAMUEL, BRADLEY AUSTIN (DDS)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:AUSTIN
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 1:1001 N LINDSAY ST
Mailing Address - Street 2:
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27262-3905
Mailing Address - Country:US
Mailing Address - Phone:336-883-2316
Mailing Address - Fax:336-883-7686
Practice Address - Street 1:1001 N LINDSAY ST
Practice Address - Street 2:
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27262-3905
Practice Address - Country:US
Practice Address - Phone:336-883-2316
Practice Address - Fax:336-883-7686
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC76521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89902TWMedicaid
NC89902TWMedicaid