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General NPI Number Information
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NPI Number | 1003729377
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Entity Type | Organization
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Legal Business Name | NORTH WICKHAM DENTISTRY PLLC
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Dates
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Enumeration Date | 09/25/2026
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Last Update Date | 09/25/2026
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Provider Practice Location Address
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Address Line | 4521 N WICKHAM RD STE 101
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City | MELBOURNE
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State | FL
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Zip | 32935-7108
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Country | US
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Telephone | 321-255-2700
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Fax |
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Provider Business Mailing Address
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Address Line | 12919 SUNSTONE AVE APT 8304
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City | ORLANDO
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State | FL
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Zip | 32832-6278
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | SAM DIRAWI
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Credential | DMD
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Telephone | 585-506-1818
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State | NULL
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