Provider Demographics
NPI:1902493182
Name:ZIJOUDI, SAM
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:
Last Name:ZIJOUDI
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 1:7320 RESEDA BLVD UNIT 370872
Mailing Address - Street 2:
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91337-7045
Mailing Address - Country:US
Mailing Address - Phone:703-303-8171
Mailing Address - Fax:
Practice Address - Street 1:6300 SHOUP AVE UNIT 8
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91367-1844
Practice Address - Country:US
Practice Address - Phone:703-303-8171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-22
Last Update Date:2021-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA105896122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty