Provider Demographics
NPI:1427534429
Name:TARAJI, SAMIM (DMD)
Entity Type:Individual
Prefix:
First Name:SAMIM
Middle Name:
Last Name:TARAJI
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 1:222 N COLUMBUS DR APT 3909
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-7824
Mailing Address - Country:US
Mailing Address - Phone:224-544-0249
Mailing Address - Fax:
Practice Address - Street 1:1211 DOLPHIN CT
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-1488
Practice Address - Country:US
Practice Address - Phone:262-436-3363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-13
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10019421223X0400X
IL019.0316461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty