Healthcare Provider Details

I. General information

NPI: 1235286642
Provider Name (Legal Business Name): SAMUEL BOWEN MAYFIELD D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4341 GAUTIER VANCLEAVE RD SUITE 3
GAUTIER MS
39553-4825
US

IV. Provider business mailing address

4341 GAUTIER VANCLEAVE RD SUITE 3
GAUTIER MS
39553-4825
US

V. Phone/Fax

Practice location:
  • Phone: 228-497-9844
  • Fax: 228-497-9499
Mailing address:
  • Phone: 228-497-9844
  • Fax: 228-497-9499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number0-31-71
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: