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General NPI Number Information
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NPI Number | 1508131350
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Entity Type | Organization
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Legal Business Name | SAM W. QUILLEN JR. DMD
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Dates
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Enumeration Date | 03/13/2012
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Last Update Date | 03/13/2012
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Provider Practice Location Address
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Address Line | 861 HWY 317 SUITE A
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City | NEON
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State | KY
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Zip | 41840-0036
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Country | US
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Telephone | 606-855-7892
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Fax | 606-855-7892
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Provider Business Mailing Address
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Address Line | PO BOX 36 SUITE A
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City | NEON
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State | KY
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Zip | 41840-0036
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Country | US
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Telephone | 606-855-7892
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Fax | 606-855-7892
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Authorized Official
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Title or Position | OWNER
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Name | DR. SAM WILEY QUILLEN JR.
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Credential | DMD
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Telephone | 606-855-7892
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 4626
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License Number State | KY
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