=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104634013
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DRS ABDELAZIZ SAMI & MAHDI DDS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/23/2024
-----------------------------------------------------
Last Update Date | 12/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2642 SOMERSVILLE RD STE B
-----------------------------------------------------
City | ANTIOCH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94509-4428
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-572-1722
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2642 SOMERSVILLE RD STE B
-----------------------------------------------------
City | ANTIOCH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94509-4428
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-572-1722
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | HEATHER RICH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 209-573-0879
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223E0200X
-----------------------------------------------------
Taxonomy Name | Endodontics
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------