Provider Demographics
NPI:1952762882
Name:MANJEET SAMRA, DDS, PC
Entity type:Organization
Organization Name:MANJEET SAMRA, DDS, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MANJEET
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-923-3013
Mailing Address - Street 1:1110 W ROBINHOOD DR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-5606
Mailing Address - Country:US
Mailing Address - Phone:209-478-4666
Mailing Address - Fax:
Practice Address - Street 1:1110 W ROBINHOOD DR
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-5606
Practice Address - Country:US
Practice Address - Phone:209-478-4666
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-20
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA622021223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty