Provider Demographics
NPI:1679534895
Name:SAMUDIO, JAVIER A (DDS)
Entity Type:Individual
Prefix:
First Name:JAVIER
Middle Name:A
Last Name:SAMUDIO
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 1:3571 BUNKER AVE
Mailing Address - Street 2:
Mailing Address - City:WANTAGH
Mailing Address - State:NY
Mailing Address - Zip Code:11793-3438
Mailing Address - Country:US
Mailing Address - Phone:516-765-3467
Mailing Address - Fax:718-471-2071
Practice Address - Street 1:1847 MOTT AVE FL 2
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-4201
Practice Address - Country:US
Practice Address - Phone:718-327-7000
Practice Address - Fax:718-471-2071
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-29
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY044530122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01400191Medicaid