Basic Information
| Provider Information | |||||||||
| NPI: | 1295265015 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FARAH | ||||||||
| FirstName: | FADI | ||||||||
| MiddleName: | AMER | ||||||||
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| Credential: | DA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1290 TREMONT ST | ||||||||
| Address2: | |||||||||
| City: | ROXBURY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021203432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174271000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 632 BLUE HILL AVE | ||||||||
| Address2: | |||||||||
| City: | DORCHESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6178253400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2017 | ||||||||
| LastUpdateDate: | 01/10/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DL13247 | MA | N | Dental Providers | Dentist | General Practice | 126800000X | DA06547 | MA | N | Dental Providers | Dental Assistant | 122300000X | DL13612 | MA | Y | Dental Providers | Dentist |
No ID Information.