Healthcare Provider Details

I. General information

NPI: 1801270996
Provider Name (Legal Business Name): KOOSHA FARNOOSH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2015
Last Update Date: 07/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1286 STATE ROUTE 3 S STE 7
CROFTON MD
21114-1340
US

IV. Provider business mailing address

1286 STATE ROUTE 3 N #7
CROFTON MD
21114
US

V. Phone/Fax

Practice location:
  • Phone: 410-721-7629
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number15963
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: