Healthcare Provider Details

I. General information

NPI: 1275895351
Provider Name (Legal Business Name): SAMOHA DENTAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2012
Last Update Date: 10/02/2020
Certification Date: 10/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 NEWCASTLE AVE
ENCINO CA
91316-3080
US

IV. Provider business mailing address

5805 WHITE OAK AVE #16714
ENCINO CA
91316-3080
US

V. Phone/Fax

Practice location:
  • Phone: 818-430-9207
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number60167
License Number StateCA

VIII. Authorized Official

Name: SHMUEL SAMOHA
Title or Position: CEO
Credential: DDS
Phone: 818-430-9207