MEDICARE: SAMIRA FAROKH D.M.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	6328	NV
2	1223P0221X	Pediatric Dentistry	S6-168	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0001719087	OTHER	NV	DRIVERS LICENSE

General Provider Information

NPI Number	:	1497091367
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMIRA FAROKH D.M.D

Provider Business Mailing Address
First Line	:	2109 BACHELOR CT
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89128-7620
Country	:	US
Telephone Number	:	702-234-8557
Fax Number	:

Provider Business Practice Location Address
First Line	:	3896 N MLK BLVD
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89032-6603
Country	:	US
Telephone Number	:	702-395-5437
Fax Number	:	702-933-0190

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/21/2012
Last Update Date	:	06/17/2019

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