Provider Demographics
NPI:1285920769
Name:ADDISON, SAMUEL N (DDS, MD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:N
Last Name:ADDISON
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8305 FALLS OF NEUSE RD STE 105
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-3546
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8305 FALLS OF NEUSE RD STE 105
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-3546
Practice Address - Country:US
Practice Address - Phone:919-841-1720
Practice Address - Fax:919-841-1725
Is Sole Proprietor?:No
Enumeration Date:2011-06-23
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC115091223S0112X
MADL-11243204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery