MEDICARE: DR. DANIEL EDGER SAMPSON MD DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	11023DDS	MN
2	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	A61108	CA

General Provider Information

NPI Number	:	1306873575
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DANIEL EDGER SAMPSON MD DDS

Provider Business Mailing Address
First Line	:	306 DEARBORN COURT
Second Line	:
City	:	EDINA
State	:	MN
Zip	:	55343
Country	:	US
Telephone Number	:	612-788-9246
Fax Number	:	612-788-5511

Provider Business Practice Location Address
First Line	:	3905 SILVER LAKE RD
Second Line	:
City	:	ST ANTHONY
State	:	MN
Zip	:	55421
Country	:	US
Telephone Number	:	612-788-9246
Fax Number	:	612-788-5511

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/26/2006
Last Update Date	:	07/08/2007

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