Healthcare Provider Details

I. General information

NPI: 1063471472
Provider Name (Legal Business Name): RISA CHERYL SAMUELS DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61-17 220TH ST
OAKLAND GARDENS NY
11364-2244
US

IV. Provider business mailing address

61-17 220TH ST
OAKLAND GARDENS NY
11364-2244
US

V. Phone/Fax

Practice location:
  • Phone: 718-225-3050
  • Fax: 718-225-5609
Mailing address:
  • Phone: 718-225-3050
  • Fax: 718-225-5609

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number040378
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: