Healthcare Provider Details

I. General information

NPI: 1811554595
Provider Name (Legal Business Name): SAMANTHA MAYES DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2019
Last Update Date: 06/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1108 E OHIO ST
CLINTON MO
64735-2458
US

IV. Provider business mailing address

802 AUTUMN DR
BELTON MO
64012-4716
US

V. Phone/Fax

Practice location:
  • Phone: 660-885-6933
  • Fax:
Mailing address:
  • Phone: 816-679-0974
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2019023103
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: