Healthcare Provider Details

I. General information

NPI: 1770322158
Provider Name (Legal Business Name): SAMUEL DEXTER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2024
Last Update Date: 08/02/2024
Certification Date: 08/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 SE GREENVILLE BLVD
GREENVILLE NC
27858-4811
US

IV. Provider business mailing address

1520 COURT AVE
MEMPHIS TN
38104-2403
US

V. Phone/Fax

Practice location:
  • Phone: 252-375-8755
  • Fax:
Mailing address:
  • Phone: 662-808-6631
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number13906
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: