Provider Demographics
NPI:1316051469
Name:SAMUELSON, GREG STUART (DDS MSD)
Entity type:Individual
Prefix:DR
First Name:GREG
Middle Name:STUART
Last Name:SAMUELSON
Suffix:
Gender:M
Credentials:DDS MSD
Other - Prefix:
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Mailing Address - Street 1:13808 W MAPLE RD
Mailing Address - Street 2:SUITE 112
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68164-6231
Mailing Address - Country:US
Mailing Address - Phone:402-493-2268
Mailing Address - Fax:402-445-8370
Practice Address - Street 1:13808 W MAPLE RD
Practice Address - Street 2:SUITE 112
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68164-6231
Practice Address - Country:US
Practice Address - Phone:402-493-2268
Practice Address - Fax:402-445-8370
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE53411223X0400X
IA76811223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025140300Medicaid
IA1225359Medicaid