Provider Demographics
NPI:1730279431
Name:DEMIRDJI, SAMUEL A (DDS, MS, PHD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:A
Last Name:DEMIRDJI
Suffix:
Gender:M
Credentials:DDS, MS, PHD
Other - Prefix:PROF
Other - First Name:SAMUEL
Other - Middle Name:A
Other - Last Name:DEMIRDJI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS, MS, INC
Mailing Address - Street 1:7199 BOULDER AVE STE 5
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:CA
Mailing Address - Zip Code:92346-3398
Mailing Address - Country:US
Mailing Address - Phone:909-864-6510
Mailing Address - Fax:
Practice Address - Street 1:7199 BOULDER AVE STE 5
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:CA
Practice Address - Zip Code:92346-3398
Practice Address - Country:US
Practice Address - Phone:909-864-6510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA484471223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics