Healthcare Provider Details

I. General information

NPI: 1629445630
Provider Name (Legal Business Name): FAY NAZARI DDS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2015
Last Update Date: 08/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13360 CLARKSVILLE PIKE
HIGHLAND MD
20777-9701
US

IV. Provider business mailing address

13360 CLARKSVILLE PIKE
HIGHLAND MD
20777-9701
US

V. Phone/Fax

Practice location:
  • Phone: 301-854-2000
  • Fax: 301-854-1122
Mailing address:
  • Phone: 301-854-2000
  • Fax: 301-854-1122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number15517
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number13973
License Number StateMD

VIII. Authorized Official

Name: DR. FAY NAZARI
Title or Position: DENTIST
Credential: DDS
Phone: 301-854-2000