=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003456716
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAMER A FARAJ DDS MS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2020
-----------------------------------------------------
Last Update Date | 01/10/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23762 US 59 STE A
-----------------------------------------------------
City | PORTER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77365
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-304-2520
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23762 US 59 STE A
-----------------------------------------------------
City | PORTER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77365
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-304-2520
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT / OWNER
-----------------------------------------------------
Name | SAMER ADNAN FARAJ
-----------------------------------------------------
Credential | DDS, MS
-----------------------------------------------------
Telephone | 859-304-2520
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------