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General NPI Number Information
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NPI Number | 1679534895
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Entity Type | Individual
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Provider Name | JAVIER A SAMUDIO DDS
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Gender | Male
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Dates
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Enumeration Date | 03/29/2006
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Last Update Date | 10/02/2012
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Provider Practice Location Address
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Address Line | 1847 MOTT AVE FL 2
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City | FAR ROCKAWAY
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State | NY
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Zip | 11691-4201
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Country | US
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Telephone | 718-327-7000
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Fax | 718-471-2071
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Provider Business Mailing Address
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Address Line | 3571 BUNKER AVE
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City | WANTAGH
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State | NY
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Zip | 11793-3438
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Country | US
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Telephone | 516-765-3467
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Fax | 718-471-2071
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 044530
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License Number State | NY
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