Provider Demographics
NPI:1801955133
Name:QUILLEN, SAM WILEY JR (DMD)
Entity type:Individual
Prefix:DR
First Name:SAM
Middle Name:WILEY
Last Name:QUILLEN
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 36
Mailing Address - Street 2:861 SUITE A
Mailing Address - City:NEON
Mailing Address - State:KY
Mailing Address - Zip Code:41840-0036
Mailing Address - Country:US
Mailing Address - Phone:606-855-7892
Mailing Address - Fax:606-855-7892
Practice Address - Street 1:HWY 317
Practice Address - Street 2:861 SUITE A BX 36
Practice Address - City:NEON
Practice Address - State:KY
Practice Address - Zip Code:41840-0036
Practice Address - Country:US
Practice Address - Phone:606-855-7892
Practice Address - Fax:606-855-7892
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY46261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice