Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | DL13612 | MA |
N | 1223G0001X | General Practice | DL13247 | MA |
N | 213EG0000X | General Practice | DL13247 | MA |
N | 126800000X | Dental Assistant | DA06547 | MA |
NPI | 1295265015 |
---|---|
Provider Name | Fadi Amer Farah |
First Address | Roxbury, MA 02120-3432 |
Second Address | Dorchester, MA 02121 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/06/2017 |
Last Update Date | 10/01/2019 |