Provider Demographics
NPI:1841076288
Name:SAMUEL C DAVIDSON DDS LLC
Entity type:Organization
Organization Name:SAMUEL C DAVIDSON DDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AILINA
Authorized Official - Middle Name:S
Authorized Official - Last Name:DAVIDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-272-1688
Mailing Address - Street 1:337 GREYBULL AVE
Mailing Address - Street 2:
Mailing Address - City:GREYBULL
Mailing Address - State:WY
Mailing Address - Zip Code:82426-2049
Mailing Address - Country:US
Mailing Address - Phone:307-765-4654
Mailing Address - Fax:307-333-0494
Practice Address - Street 1:337 GREYBULL AVE
Practice Address - Street 2:
Practice Address - City:GREYBULL
Practice Address - State:WY
Practice Address - Zip Code:82426-2049
Practice Address - Country:US
Practice Address - Phone:307-765-4654
Practice Address - Fax:307-333-0494
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-01
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty