Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 61610 | CA |
N | 1223D0001X | Dental Public Health | 61610 | CA |
N | 1223E0200X | Endodontist | 61610 | CA |
N | 1223G0001X | General Practice | 61610 | CA |
N | 213EG0000X | General Practice | 61610 | CA |
N | 1223P0106X | Oral and Maxillofacial Pathology | 61610 | CA |
N | 1223P0221X | Pediatric Dentist | 61610 | CA |
N | 1223P0300X | Periodontist | 61610 | CA |
N | 1223P0700X | Prosthodontist | 61610 | CA |
N | 1223S0112X | Oral and Maxillofacial Surgeon | 61610 | CA |
N | 1223X0008X | Oral and Maxillofacial Radiology | 61610 | CA |
N | 1223X0400X | Orthodontists | 61610 | CA |
NPI | 1689921025 |
---|---|
Provider Name | Dr. Sameh Said Sallam |
First Address | Moreno Valley, CA 92555-2368 |
Second Address | Moreno Valley, CA 92555-2368 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/08/2012 |
Last Update Date | 14/08/2012 |