Provider Demographics
NPI:1629205661
Name:GANJI, SAM JOSHUA (DDS)
Entity Type:Individual
Prefix:DR
First Name:SAM
Middle Name:JOSHUA
Last Name:GANJI
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 1:14650 AVIATION BLVD STE 220
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-6666
Mailing Address - Country:US
Mailing Address - Phone:310-643-8045
Mailing Address - Fax:310-643-8410
Practice Address - Street 1:14650 AVIATION BLVD STE 220
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-6666
Practice Address - Country:US
Practice Address - Phone:310-643-8045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-17
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58353122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist