Healthcare Provider Details

I. General information

NPI: 1790593580
Provider Name (Legal Business Name): SAMRAH RIAZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/25/2024
Last Update Date: 07/16/2025
Certification Date: 07/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2719 CALUMET AVE
MANITOWOC WI
54220-5546
US

IV. Provider business mailing address

1801 BURR OAK CT
WAUKESHA WI
53189-8400
US

V. Phone/Fax

Practice location:
  • Phone: 920-686-2333
  • Fax:
Mailing address:
  • Phone: 262-744-5838
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6001852-15
License Number StateWI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: