Provider Demographics
NPI:1760881619
Name:HALAKA, SAMIR
Entity Type:Individual
Prefix:
First Name:SAMIR
Middle Name:
Last Name:HALAKA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6767 W SUNSET BLVD
Mailing Address - Street 2:SUITE 25
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90028-7177
Mailing Address - Country:US
Mailing Address - Phone:323-469-8816
Mailing Address - Fax:
Practice Address - Street 1:6767 W SUNSET BLVD
Practice Address - Street 2:SUITE 25
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90028-7177
Practice Address - Country:US
Practice Address - Phone:323-469-8816
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-16
Last Update Date:2014-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37115122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA276267Medicare PIN