=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497432256
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMUEL ADAMSON DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/03/2023
-----------------------------------------------------
Last Update Date | 07/03/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3920 W BROADWAY AVE
-----------------------------------------------------
City | ROBBINSDALE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55422-2210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-535-5555
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 110 INDIAN HILLS LN
-----------------------------------------------------
City | CIRCLE PINES
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55014-4500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-220-4754
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | D14943
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------