Healthcare Provider Details

I. General information

NPI: 1437164860
Provider Name (Legal Business Name): SAMUEL JOSEPH LAVALLEY JR. D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 10TH ST
MENOMINEE MI
49858-2954
US

IV. Provider business mailing address

1520 10TH ST
MENOMINEE MI
49858-2954
US

V. Phone/Fax

Practice location:
  • Phone: 906-863-8522
  • Fax:
Mailing address:
  • Phone: 906-863-8522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901012364
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: