Provider Demographics
NPI:1144610247
Name:SAMUEL DEMIRDJI, DDS, MS, INC
Entity Type:Organization
Organization Name:SAMUEL DEMIRDJI, DDS, MS, INC
Other - Org Name:SDORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DEMIRDJI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS , MS
Authorized Official - Phone:909-864-6510
Mailing Address - Street 1:7199 BOULDER AVE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:HIGHLAND
Mailing Address - State:CA
Mailing Address - Zip Code:92346-3398
Mailing Address - Country:US
Mailing Address - Phone:909-864-6510
Mailing Address - Fax:909-864-7410
Practice Address - Street 1:7199 BOULDER AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:HIGHLAND
Practice Address - State:CA
Practice Address - Zip Code:92346-3398
Practice Address - Country:US
Practice Address - Phone:909-864-6510
Practice Address - Fax:909-864-7410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-27
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA484471223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty