Healthcare Provider Details

I. General information

NPI: 1689921025
Provider Name (Legal Business Name): SAMEH SAID SALLAM BDS,DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2012
Last Update Date: 08/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26468 SAND PALM CT
MORENO VALLEY CA
92555-2368
US

IV. Provider business mailing address

26468 SAND PALM CT
MORENO VALLEY CA
92555-2368
US

V. Phone/Fax

Practice location:
  • Phone: 951-807-6510
  • Fax:
Mailing address:
  • Phone: 951-807-6510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number61610
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number61610
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number61610
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number61610
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number61610
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number61610
License Number StateCA
# 7
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number61610
License Number StateCA
# 8
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number61610
License Number StateCA
# 9
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number61610
License Number StateCA
# 10
Primary TaxonomyN
Taxonomy Code1223X0008X
TaxonomyOral and Maxillofacial Radiology Dentistry
License Number61610
License Number StateCA
# 11
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number61610
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: