MEDICARE: DR. FARHAD AZIZZADEH DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	046904	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1588648828
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. FARHAD AZIZZADEH DDS

Provider Business Mailing Address
First Line	:	96 09 SPRINGFIELD BLVD
Second Line	:	SUITE 206
City	:	QUEENS VILLAGE
State	:	NY
Zip	:	11429
Country	:	US
Telephone Number	:	718-470-7700
Fax Number	:	718-740-8005

Provider Business Practice Location Address
First Line	:	96 09 SPRINGFIELD BLVD
Second Line	:	SUITE 206
City	:	QUEENS VILLAGE
State	:	NY
Zip	:	11429
Country	:	US
Telephone Number	:	718-470-7700
Fax Number	:	718-740-8005

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/30/2005
Last Update Date	:	11/13/2014

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