=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588015069
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMUEL JAMES HUTTON DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2016
-----------------------------------------------------
Last Update Date | 06/27/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2500 BROWNS LN STE B
-----------------------------------------------------
City | JONESBORO
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72401-6107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-972-1200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1169 UNION AVE APT 453
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38104-6679
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-797-5748
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 4119
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------