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General NPI Number Information
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NPI Number | 1801955133
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Entity Type | Individual
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Provider Name | SAM WILEY QUILLEN JR. DMD
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Gender | Male
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Dates
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Enumeration Date | 12/06/2006
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Last Update Date | 12/13/2013
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Provider Practice Location Address
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Address Line | HWY 317 861 SUITE A BX 36
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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 36 861 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 |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 4626
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License Number State | KY
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