Provider Demographics
NPI:1114241452
Name:SOURI, SAMAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:SAMAN
Middle Name:
Last Name:SOURI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 COMMERCE DR
Mailing Address - Street 2:SUITE 108
Mailing Address - City:FT WASHINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:19034-2714
Mailing Address - Country:US
Mailing Address - Phone:267-460-4254
Mailing Address - Fax:215-646-6166
Practice Address - Street 1:456 SCHOOL LN
Practice Address - Street 2:SUITE 102
Practice Address - City:HARLEYSVILLE
Practice Address - State:PA
Practice Address - Zip Code:19438-1703
Practice Address - Country:US
Practice Address - Phone:215-513-7172
Practice Address - Fax:215-513-7192
Is Sole Proprietor?:No
Enumeration Date:2010-03-15
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053462-1122300000X
PADS0384271223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist