Healthcare Provider Details

I. General information

NPI: 1245104827
Provider Name (Legal Business Name): MESK SAMARA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2025
Last Update Date: 10/06/2025
Certification Date: 10/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12880 CENTRAL AVE
BOULDER CREEK CA
95006-9114
US

IV. Provider business mailing address

16370 MATILIJA DR
LOS GATOS CA
95030-3079
US

V. Phone/Fax

Practice location:
  • Phone: 831-338-1888
  • Fax:
Mailing address:
  • Phone: 708-835-1968
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number112426
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: