Healthcare Provider Details

I. General information

NPI: 1154676872
Provider Name (Legal Business Name): FERISHTA FAQEERI DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2012
Last Update Date: 03/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 NE 1ST ST
TRENTON FL
32693-3428
US

IV. Provider business mailing address

4011 NW 65TH AVE
GAINESVILLE FL
32653-8371
US

V. Phone/Fax

Practice location:
  • Phone: 352-463-3120
  • Fax:
Mailing address:
  • Phone: 352-665-1097
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number19860
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: