Healthcare Provider Details

I. General information

NPI: 1942332309
Provider Name (Legal Business Name): NICOLAS WADIH FAKHOURY DMD PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 LINTON BLVD STE C5
DELRAY BEACH FL
33444
US

IV. Provider business mailing address

1100 LINTON BLVD STE C5
DELRAY BEACH FL
33444
US

V. Phone/Fax

Practice location:
  • Phone: 561-278-4475
  • Fax: 561-278-3484
Mailing address:
  • Phone: 561-278-4475
  • Fax: 561-278-3484

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN0014291
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: