Healthcare Provider Details

I. General information

NPI: 1407545163
Provider Name (Legal Business Name): SAMAH NOR BOUYAKOUB DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2023
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35070 GERMANNA HEIGHTS DR STE B
LOCUST GROVE VA
22508-3108
US

IV. Provider business mailing address

4218 PENNER LN
FAIRFAX VA
22033-3448
US

V. Phone/Fax

Practice location:
  • Phone: 540-399-9841
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401420039
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: