Provider Demographics
NPI:1508081449
Name:MOUCHAMEL, SAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:SAM
Middle Name:
Last Name:MOUCHAMEL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:SULAIMAN
Other - Middle Name:
Other - Last Name:MOUCHAMEL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1319 N SAN FERNANDO BLVD
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91504
Mailing Address - Country:US
Mailing Address - Phone:818-557-2299
Mailing Address - Fax:818-557-8749
Practice Address - Street 1:1319 N SAN FERNANDO BLVD
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91504
Practice Address - Country:US
Practice Address - Phone:818-557-2299
Practice Address - Fax:818-557-8749
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40861122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG9109701OtherMEDICAL