Healthcare Provider Details

I. General information

NPI: 1790995165
Provider Name (Legal Business Name): MOSTAFA FAKHRZADEH DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

153 BROAD ST FLEMINGTON MALL FAMILY AND COSMETIC DENTAL GROUP
FLEMINGTON NJ
08822-1629
US

IV. Provider business mailing address

30 FRESH PONDS RD
EAST BRUNSWICK NJ
08816-2511
US

V. Phone/Fax

Practice location:
  • Phone: 908-782-9790
  • Fax:
Mailing address:
  • Phone: 732-422-0749
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22DI01667500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: