Provider Demographics
NPI:1114588019
Name:VAUGHN-IBRAHIM, SAMIYRA SEYMONE (DDS)
Entity Type:Individual
Prefix:
First Name:SAMIYRA
Middle Name:SEYMONE
Last Name:VAUGHN-IBRAHIM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4055 RIDGE AVE APT 5607
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1590
Mailing Address - Country:US
Mailing Address - Phone:301-646-0731
Mailing Address - Fax:
Practice Address - Street 1:5201 HAVERFORD AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19139-1401
Practice Address - Country:US
Practice Address - Phone:215-472-6097
Practice Address - Fax:215-472-6112
Is Sole Proprietor?:No
Enumeration Date:2019-06-23
Last Update Date:2019-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS042140122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist