Provider Demographics
NPI:1497001630
Name:OTHMAN, SAMER MUFID (DDS)
Entity Type:Individual
Prefix:DR
First Name:SAMER
Middle Name:MUFID
Last Name:OTHMAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4705 NORTHSIDE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-1698
Mailing Address - Country:US
Mailing Address - Phone:478-207-6939
Mailing Address - Fax:
Practice Address - Street 1:4705 NORTHSIDE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-1698
Practice Address - Country:US
Practice Address - Phone:478-207-6939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-25
Last Update Date:2014-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0146861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice