Healthcare Provider Details

I. General information

NPI: 1831884204
Provider Name (Legal Business Name): NICOLE SAMOOHI DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2023
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20712 NORTHERN BLVD
BAYSIDE NY
11361-3107
US

IV. Provider business mailing address

273 SETON HALL DR
PARAMUS NJ
07652-5650
US

V. Phone/Fax

Practice location:
  • Phone: 718-819-8202
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number064405
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: