Healthcare Provider Details

I. General information

NPI: 1609365675
Provider Name (Legal Business Name): SAM JAMEEL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2018
Last Update Date: 08/29/2024
Certification Date: 08/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2340 LEBANON PIKE
NASHVILLE TN
37214-2411
US

IV. Provider business mailing address

260 W FOOTHILL BLVD
RIALTO CA
92376-5048
US

V. Phone/Fax

Practice location:
  • Phone: 909-546-7064
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number102404
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number12438
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: