Provider Demographics
NPI:1487742375
Name:SCROGGINS, SAMUEL (DMD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:SCROGGINS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3580 KEAGY RD SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-1152
Mailing Address - Country:US
Mailing Address - Phone:540-989-5257
Mailing Address - Fax:540-989-5259
Practice Address - Street 1:3580 KEAGY RD SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-1152
Practice Address - Country:US
Practice Address - Phone:540-989-5257
Practice Address - Fax:540-989-5259
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014138111223S0112X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009911387Medicaid
AL510-06443OtherBLUE CROSS BLUE SHIELD
AL51529738OtherBLUE CROSS#-EASTERN DENTA
AL009932141Medicaid
AL009911387Medicaid