Healthcare Provider Details

I. General information

NPI: 1578092771
Provider Name (Legal Business Name): SALAR AZAD DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2017
Last Update Date: 07/16/2020
Certification Date: 07/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 MILL POND RD
FREDERICK MD
21701-9427
US

IV. Provider business mailing address

1020 MILL POND RD STE F
FREDERICK MD
21701-9428
US

V. Phone/Fax

Practice location:
  • Phone: 240-423-4243
  • Fax:
Mailing address:
  • Phone: 240-423-4243
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number16369
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDEN1002104
License Number StateDC
# 3
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number16369
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: