Provider Demographics
NPI:1366863250
Name:DIRAWI, SAM (DMD)
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:
Last Name:DIRAWI
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 1:2060 FAIRPORT NINE MILE POINT RD
Mailing Address - Street 2:
Mailing Address - City:PENFIELD
Mailing Address - State:NY
Mailing Address - Zip Code:14526-1749
Mailing Address - Country:US
Mailing Address - Phone:585-377-5810
Mailing Address - Fax:585-377-1121
Practice Address - Street 1:2060 FAIRPORT NINE MILE POINT RD
Practice Address - Street 2:
Practice Address - City:PENFIELD
Practice Address - State:NY
Practice Address - Zip Code:14526-1749
Practice Address - Country:US
Practice Address - Phone:585-377-5810
Practice Address - Fax:585-377-1121
Is Sole Proprietor?:No
Enumeration Date:2013-12-19
Last Update Date:2018-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0593931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05023372Medicaid