Provider Demographics
NPI:1144769639
Name:EVELYN T SAMUEL DMD PC
Entity type:Organization
Organization Name:EVELYN T SAMUEL DMD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:EVELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMUEL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:571-297-4302
Mailing Address - Street 1:8301 ARLINGTON BLVD
Mailing Address - Street 2:STE. 207
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-2902
Mailing Address - Country:US
Mailing Address - Phone:571-297-4302
Mailing Address - Fax:
Practice Address - Street 1:8301 ARLINGTON BLVD
Practice Address - Street 2:STE. 207
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-2902
Practice Address - Country:US
Practice Address - Phone:571-297-4302
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-16
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401413391122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty