Provider Demographics
NPI:1245240571
Name:SAMUYLOVA, RAISA (DDS)
Entity Type:Individual
Prefix:
First Name:RAISA
Middle Name:
Last Name:SAMUYLOVA
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 1:5 MANOR DR
Mailing Address - Street 2:SUITE #1C
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07106
Mailing Address - Country:US
Mailing Address - Phone:973-372-7500
Mailing Address - Fax:973-372-1843
Practice Address - Street 1:5 MANOR DR
Practice Address - Street 2:SUITE #1C
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07106
Practice Address - Country:US
Practice Address - Phone:973-372-7500
Practice Address - Fax:973-372-1843
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ19201122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ60021407OtherHMO
NJ6428908Medicaid