Healthcare Provider Details

I. General information

NPI: 1215429642
Provider Name (Legal Business Name): SAMUEL TEAGUE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2018
Last Update Date: 09/20/2024
Certification Date: 09/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 MERCURY VILLAGE DR
DURANGO CO
81301-8955
US

IV. Provider business mailing address

150 MERCURY VILLAGE DR
DURANGO CO
81301-8955
US

V. Phone/Fax

Practice location:
  • Phone: 970-335-2342
  • Fax:
Mailing address:
  • Phone: 970-335-2422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number00203598
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDEN.00203598
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: