1033565528 NPI number — FATEMI FAMILY DENTISTRY LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033565528 NPI number — FATEMI FAMILY DENTISTRY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FATEMI FAMILY DENTISTRY LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033565528
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/13/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
64 SOUTH FREDERICK AVE #209
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GAITHERSBURG
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20877
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-740-2686
Provider Business Mailing Address Fax Number:
240-238-2921

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
604 S FREDERICK AVE
Provider Second Line Business Practice Location Address:
#209
Provider Business Practice Location Address City Name:
GAITHERSBURG
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20877-1275
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-740-2686
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/13/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
FATEMI
Authorized Official First Name:
MOHAMMAD
Authorized Official Middle Name:
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
301-740-2686

Provider Taxonomy Codes

  • Taxonomy code: 1223P0700X , with the licence number:  11720 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)