Healthcare Provider Details

I. General information

NPI: 1710449277
Provider Name (Legal Business Name): SAMUEL M ELCIK DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2019
Last Update Date: 06/23/2021
Certification Date: 06/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 NW CARLON AVE
BEND OR
97703-2636
US

IV. Provider business mailing address

2293 S 800 E
SALT LAKE CITY UT
84106-1872
US

V. Phone/Fax

Practice location:
  • Phone: 541-389-1884
  • Fax:
Mailing address:
  • Phone: 443-822-9965
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD11260
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: