Provider Demographics
NPI:1023202264
Name:SAMRA, ED (DDS)
Entity Type:Individual
Prefix:DR
First Name:ED
Middle Name:
Last Name:SAMRA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 CORPORATE DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LADERA RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:92694-1152
Mailing Address - Country:US
Mailing Address - Phone:949-364-0006
Mailing Address - Fax:949-364-0007
Practice Address - Street 1:800 CORPORATE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:LADERA RANCH
Practice Address - State:CA
Practice Address - Zip Code:92694-1152
Practice Address - Country:US
Practice Address - Phone:949-364-0006
Practice Address - Fax:949-364-0007
Is Sole Proprietor?:No
Enumeration Date:2007-08-30
Last Update Date:2010-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB413351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA516613Medicare PIN