=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821447350
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMUEL MCKENZIE YOUNG BARTLETT D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2016
-----------------------------------------------------
Last Update Date | 06/06/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3712 LAWNDALE DR
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27455-3065
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-419-1099
-----------------------------------------------------
Fax | 336-419-1104
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3712 LAWNDALE DR
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27455-3065
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-419-1099
-----------------------------------------------------
Fax | 336-419-1104
-----------------------------------------------------
=====================================================
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 | 10382
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------