Provider Demographics
NPI:1902421381
Name:BARSOUM, SAMIR
Entity Type:Individual
Prefix:
First Name:SAMIR
Middle Name:
Last Name:BARSOUM
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 1:2638 GUNN HWY
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:FL
Mailing Address - Zip Code:33556-2541
Mailing Address - Country:US
Mailing Address - Phone:727-312-5035
Mailing Address - Fax:
Practice Address - Street 1:2638 GUNN HWY
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:FL
Practice Address - Zip Code:33556-2541
Practice Address - Country:US
Practice Address - Phone:727-325-2403
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-11
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN24957122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist