Healthcare Provider Details

I. General information

NPI: 1548469398
Provider Name (Legal Business Name): SAMANTHA JEAN SUTTON DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2007
Last Update Date: 07/05/2023
Certification Date: 07/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1303 STATE ST
MOUND CITY MO
64470-1717
US

IV. Provider business mailing address

718 CHERRY ST
CHILLICOTHEE MO
64601-2210
US

V. Phone/Fax

Practice location:
  • Phone: 660-442-5464
  • Fax:
Mailing address:
  • Phone: 660-973-3615
  • Fax: 660-646-3907

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2007017222
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number2007017222
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2007017222
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: