Healthcare Provider Details

I. General information

NPI: 1497091367
Provider Name (Legal Business Name): SAMIRA FAROKH D.M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2012
Last Update Date: 06/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3896 N MLK BLVD
NORTH LAS VEGAS NV
89032-6603
US

IV. Provider business mailing address

2109 BACHELOR CT
LAS VEGAS NV
89128-7620
US

V. Phone/Fax

Practice location:
  • Phone: 702-395-5437
  • Fax: 702-933-0190
Mailing address:
  • Phone: 702-234-8557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number6328
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberS6-168
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: