Healthcare Provider Details

I. General information

NPI: 1255582078
Provider Name (Legal Business Name): MARTIN E. SAMUEL, DDS,MD,SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2008
Last Update Date: 10/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2741 W LAYTON AVE SUITE 206
MILWAUKEE WI
53221-2600
US

IV. Provider business mailing address

2741 W LAYTON AVE SUITE 206
MILWAUKEE WI
53221-2600
US

V. Phone/Fax

Practice location:
  • Phone: 414-281-9824
  • Fax: 414-281-9835
Mailing address:
  • Phone: 414-281-9824
  • Fax: 414-281-9835

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. JOYCE ROSE GRUNERT
Title or Position: ADMINISTRATOR
Credential:
Phone: 414-281-9824