Provider Demographics
NPI:1063520542
Name:SAMUELSON, BART AARON (DDS)
Entity type:Individual
Prefix:DR
First Name:BART
Middle Name:AARON
Last Name:SAMUELSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 FEDERAL AVE
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-2326
Mailing Address - Country:US
Mailing Address - Phone:605-348-4657
Mailing Address - Fax:605-348-4382
Practice Address - Street 1:200 FEDERAL AVE
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-2326
Practice Address - Country:US
Practice Address - Phone:605-348-4657
Practice Address - Fax:605-348-4382
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDD06071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice