Provider Demographics
NPI:1215450952
Name:SAMUELSON, BENJAMIN E (DMD, MS)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:E
Last Name:SAMUELSON
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5564 GROVE BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35226-4601
Mailing Address - Country:US
Mailing Address - Phone:205-988-9678
Mailing Address - Fax:
Practice Address - Street 1:5564 GROVE BLVD STE A
Practice Address - Street 2:
Practice Address - City:HOOVER
Practice Address - State:AL
Practice Address - Zip Code:35226-4601
Practice Address - Country:US
Practice Address - Phone:205-988-9678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-25
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL6358C1122300000X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
No122300000XDental ProvidersDentist