Healthcare Provider Details

I. General information

NPI: 1376509117
Provider Name (Legal Business Name): MARK FARAGE D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6650 CROSSING DR.SE
KENTWOOD MI
49508
US

IV. Provider business mailing address

6650 CROSSING DR.SE
KENTWOOD MI
49508
US

V. Phone/Fax

Practice location:
  • Phone: 616-554-0296
  • Fax: 616-554-9981
Mailing address:
  • Phone: 616-554-0296
  • Fax: 616-554-9981

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number13447
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: