Healthcare Provider Details

I. General information

NPI: 1316512767
Provider Name (Legal Business Name): FADI A. FARSAKH DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2021
Last Update Date: 08/29/2026
Certification Date: 08/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19339 VICTORY BLVD UNIT 102
RESEDA CA
91335
US

IV. Provider business mailing address

19339 VICTORY BLVD UNIT 102
RESEDA CA
91335
US

V. Phone/Fax

Practice location:
  • Phone: 818-572-2858
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDDS108775
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDDS108775
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: