Provider Demographics
NPI:1497091367
Name:FAROKH, SAMIRA (DMD)
Entity Type:Individual
Prefix:
First Name:SAMIRA
Middle Name:
Last Name:FAROKH
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2109 BACHELOR CT
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-7620
Mailing Address - Country:US
Mailing Address - Phone:702-234-8557
Mailing Address - Fax:
Practice Address - Street 1:3896 N MLK BLVD
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032-6603
Practice Address - Country:US
Practice Address - Phone:702-395-5437
Practice Address - Fax:702-933-0190
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-21
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV6328122300000X
NVS6-1681223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV0001719087OtherDRIVERS LICENSE