=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902763840
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAMUEL DASTRUP DDS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/05/2026
-----------------------------------------------------
Last Update Date | 01/05/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 430 S SALISBURY AVE
-----------------------------------------------------
City | SPENCER
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28159-2239
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-633-1260
-----------------------------------------------------
Fax | 704-633-1263
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 113
-----------------------------------------------------
City | SPENCER
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28159-0113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-671-8491
-----------------------------------------------------
Fax | 704-633-1263
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DENTIST
-----------------------------------------------------
Name | DR. SAMUEL DASTRUP
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 801-821-8982
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------