Healthcare Provider Details

I. General information

NPI: 1104987841
Provider Name (Legal Business Name): JAMES L SAMPLES DDS ,PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411A N JEFFERSON ST
CARROLLTON MO
64633-1945
US

IV. Provider business mailing address

122 WALNUT DR
CARROLLTON MO
64633-1376
US

V. Phone/Fax

Practice location:
  • Phone: 660-542-1653
  • Fax:
Mailing address:
  • Phone: 660-542-2512
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number11650
License Number StateMO

VIII. Authorized Official

Name: DR. JAMES LEE SAMPLES
Title or Position: OWNER
Credential: DDS
Phone: 660-542-1653